Failure to Implement Antibiotic Stewardship Program and Protocols
Penalty
Summary
The facility failed to implement its antibiotic stewardship program and antibiotic use protocols as outlined in its policy. Review of the June 2025 antibiotic line list showed that while the list included resident names, infections, antibiotics, and start/end dates, it did not indicate whether antibiotics were appropriate for use or if the Loeb Minimum Criteria was utilized. Specifically, a resident was prescribed Bactrim DS and Nitrofurantoin for urinary tract infection prophylaxis, but there was no documentation in the medical record of the Loeb's minimum criteria evaluation prior to the initiation of antibiotics. Interviews with the Infection Preventionist revealed an inability to explain or provide documentation that the Loeb's criteria were used for antibiotic initiation during the month in question. The Infection Preventionist also confirmed that data regarding resident infections and antibiotic use had not been discussed in QAPI meetings since their employment began. The Administrator corroborated that there had been no discussion of these topics in recent QAPI meetings, confirming the facility's failure to monitor and discuss antibiotic use as required by its own protocols.