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F0881
D

Failure to Document and Maintain Antibiotic Stewardship Program

Yerington, Nevada Survey Completed on 07-24-2025

Penalty

No penalty information released
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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 failed to maintain an Antibiotic Stewardship Program (ASP) that included the tracking and trending of infections and antibiotic use from August 2024 through May 30, 2025. During a survey, the facility was unable to provide documented evidence of an ASP for this period. The Infection Preventionist (IP) confirmed that while infections and antibiotic use were monitored for trends, no documentation of these findings was maintained. The IP began employment at the facility on May 12, 2025, and only started documenting tracking and trending of infections and antibiotic use on May 30, 2025. The interim Director of Nursing (DON) also confirmed the absence of documented evidence for the ASP, including tracking and trending activities during the specified period. According to the facility's policy, the ASP should have included proactive monitoring of antimicrobial prescriptions, record-keeping of antibiotic use, and monthly documentation of all infections. However, these procedures were not followed or documented as required, resulting in the deficiency.

See complete original report
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