Failure to Monitor and Review Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, specifically lacking protocols and a system to monitor the appropriateness of antibiotic use, including prophylactic antibiotics. Document review and staff interviews revealed that the facility was not tracking or reviewing the ongoing use of prophylactic antibiotics for any residents, and this deficiency had the potential to affect all 72 residents. The Antibiotic Surveillance and Symptom Tracker report did not include prophylactic antibiotic tracking, and the infection preventionist confirmed that she was not monitoring or able to identify residents on prophylactic antibiotics. The consulting pharmacist reviewed antibiotics for appropriate dosing but did not assess the duration of use, leaving this responsibility to the provider, while the infection preventionist relied on pharmacy review without understanding the process. For one resident reviewed for oral antibiotic use, the medical record showed an ongoing order for cephalexin for UTI prophylaxis without documentation of review for continued appropriateness. The resident reported being started on cephalexin by a urologist after multiple UTIs but was unclear on the intended duration. The assistant director of nursing and the nurse practitioner both confirmed that the continued use of the antibiotic had not been reviewed since admission, with the nurse practitioner stating she would not review the medication until the resident transitioned to long-term care. Facility policy required monthly chart reviews and pharmacy oversight for antibiotic use, but these processes were not being followed for prophylactic antibiotics.