Failure to Assess Continued Need for Long-Term Antibiotic Therapy
Penalty
Summary
A deficiency was identified when a resident's drug regimen included an antibiotic, Minocycline HCI 100 mg, that had been ordered for infection and inflammatory reaction due to an internal right knee prosthesis. The antibiotic order, which began in early 2023, did not have an identified end date and had not been reassessed for continued need. The resident, who was cognitively intact and required extensive assistance with care, was also taking a diuretic and an opioid. The infection preventionist was unaware that the resident was still receiving the antibiotic and had not reviewed its ongoing necessity, as the medication was being administered by a trained medication aide rather than the charge nurse, which contributed to the oversight. Further interviews revealed that the consulting pharmacist was also unaware of any reassessment for the continued use of the antibiotic and noted that while long-term use of Minocycline is not uncommon, the lack of an end date should have prompted a review. The director of nursing acknowledged that the antibiotic order should not have been overlooked for such an extended period and that orders are expected to be reviewed by nursing staff, the pharmacist, and the provider. The facility's antibiotic stewardship policy requires all antibiotic orders to include a diagnosis, medication, dose, route, and duration, and limits prophylactic use based on physician documentation, but these procedures were not followed in this case.