Failure to Implement Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to implement antibiotic use protocols that address unnecessary or inappropriate antibiotic use for one resident reviewed for antibiotic stewardship. Specifically, a physician's order was issued for Cipro to treat a urinary tract infection (UTI), but the resident's medical record did not include documentation of an antibiotic time out for this medication. Additionally, the Revised McGeer Criteria for Infection Surveillance Checklist, completed for the UTI, indicated that the infection did not meet the established criteria for initiating antibiotic therapy. An interview with the Director of Nursing confirmed that the facility's policy on Antibiotic Management did not include provisions for antibiotic stewardship or the use of antibiotic time outs. The facility did not document antibiotic time outs, despite following CDC guidelines for antibiotic use, which recommend implementing an antibiotic review process for all antibiotics prescribed. The facility's policy focused on individualized prescribing and lab work but lacked standardized stewardship practices as outlined by the CDC.