Failure to Implement and Document Comprehensive Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and operationalize a comprehensive Antibiotic Stewardship Program, as evidenced by incomplete documentation, lack of analysis, and insufficient monitoring of antibiotic use for four residents reviewed for antimicrobial treatment. Infection control documentation for January 2025 did not include a summary or analysis of infections, and the Monthly Infection Surveillance Report was missing critical information, such as whether infections met McGeer’s Criteria for 15 out of 31 cases. The infection control nurse (IC RN K) was unable to explain missing data or confirm the appropriateness of antibiotic treatments due to incomplete records and lack of laboratory results. For one resident treated for a UTI, the line listing omitted the date antibiotic treatment was started, did not specify if the infection was facility or community acquired, and lacked laboratory testing results. The IC nurse could not explain why certain organisms were not documented or confirm if the prescribed antibiotic was appropriate, as sensitivity data was missing. Another resident was treated for a UTI, but the facility lacked a culture and sensitivity report, and the infection was incorrectly classified as community acquired when it was actually facility acquired. The IC nurse could not evaluate the appropriateness of antibiotic treatment due to missing documentation and assessments. Additional deficiencies included a resident started on two antibiotics after a podiatry visit without any progress notes, assessment, or documentation of infection signs and symptoms. The IC nurse and DON were unable to provide documentation or rationale for the antibiotic orders, with the DON indicating antibiotics may have been prescribed prophylactically. Another resident was prescribed a prolonged course of antibiotics without documentation of the infection being treated, the organism involved, or monitoring of ongoing antibiotic use. The resident was not included in the infection control line listing, and the facility could not provide supporting documentation for the extended antibiotic therapy.