Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and operationalize its antibiotic stewardship program as outlined in its own policy, resulting in inaccurate monitoring of antibiotic use for all 38 residents. Review of the Infection Prevention and Control binder showed that multiple residents who had taken antibiotics during the look-back period were marked as not meeting the criteria for antibiotic use on tracking sheets, despite the facility's protocol requiring the use of McGeer's Criteria. The policy mandates that the Infection Preventionist, with oversight from the DON, coordinates stewardship activities, maintains documentation, and ensures protocols are followed, including the use of McGeer's Criteria to define infections and the review of antibiotic orders for appropriateness. During an interview, the DON, who also served as the Infection Control Preventionist, admitted that neither she nor the physicians consistently used McGeer's Criteria or any other accredited antibiotic criteria when prescribing antibiotics. Instead, decisions were sometimes based on clinical experience and observed symptoms, even when residents did not meet established criteria. The DON also lacked the required Infection Control Preventionist training certificate. The facility's policy further requires regular monitoring, documentation, and review of antibiotic use, as well as annual education for nursing staff, but these processes were not consistently followed, as evidenced by the documentation and interview findings.