Failure to Track Infections and Antibiotic Use in QAPI/ASP
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility's QAPI committee failed to identify and address a lapse in tracking and trending infections and antibiotic use as part of the Antibiotic Stewardship Program (ASP). According to interviews and document review, the facility stopped monitoring infection prevention and control from August 2024 through May 2025 due to the absence of an Infection Preventionist on staff. As a result, the QAPI committee did not recognize or act upon the lack of antibiotic stewardship tracking for resident antibiotics. Facility policy required the performance improvement plan to monitor systems of care, including medication management and infection prevention and control, but these measures were not followed during the specified period.