Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish and implement an effective antibiotic stewardship program, as evidenced by the lack of written protocols for antibiotic use, insufficient documentation, and the absence of a monitoring system to provide feedback to prescribing practitioners. The Infection Control policy referenced antibiotic stewardship but did not include specific protocols for antibiotic use, procedures for residents admitted on antibiotics, or a system for feedback and documentation. During interviews, the Infection Preventionist described a general process for identifying infections and initiating antibiotics but did not reference any formalized, written procedures or monitoring systems. A review of the electronic medical record for a resident admitted with a urinary catheter revealed multiple deficiencies in antibiotic management and documentation. The resident exhibited symptoms of a urinary tract infection (UTI), and laboratory tests were conducted. Despite positive urinalysis results, antibiotics were initiated without documented justification or evidence that the physician had been notified. There were conflicting entries for two different antibiotics, with no documentation regarding consideration of renal function or culture results. The medical provider did not document in the facility's EMR, and there was no care plan for the UTI or antibiotic therapy. The facility was unable to provide additional documentation to demonstrate that antibiotic therapy was consistent with an antibiotic stewardship program.