Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program to monitor and ensure appropriate antibiotic use, as evidenced by record reviews, interviews, and policy review. Specifically, the facility did not consistently utilize McGeer criteria to assess the necessity and appropriateness of antibiotic prescriptions for residents, including those with chronic infections or those admitted from hospitals. In multiple cases, antibiotics were administered to residents for infections that did not meet McGeer criteria, and there was no documentation that physicians were informed of these findings to reconsider or evaluate the need for antibiotic therapy. Medical record reviews revealed that several residents received antibiotics for various infections, such as UTIs, pneumonia, and chronic wounds, without meeting the established criteria for infection surveillance. In some instances, antibiotics were prescribed without a documented stop date or duration, and there was no evidence of ongoing physician review or evaluation of the continued necessity for these medications. For example, one resident received cephalexin for an extended period without documented reassessment, and the facility was unable to provide evidence that the appropriateness of this ongoing antibiotic use was reviewed by a physician. Interviews with facility leadership, including the infection preventionist and the DON, confirmed that McGeer criteria were not applied to all residents, particularly those with chronic infections or those under the care of outside physicians. The facility's policy required annual review and staff education on antibiotic stewardship, but there was no evidence of recent policy review or staff training. The infection preventionist reported challenges in communicating with non-facility physicians and indicated that the facility did not intervene in antibiotic management unless the infection originated within the facility.