Failure to Implement Comprehensive Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement a comprehensive antibiotic stewardship program to adequately monitor infections and determine the appropriateness of antibiotic use for all residents. Infection control logs only included residents who were started on antibiotics and did not document other possible infectious findings, symptom onset dates, specific symptoms, or whether diagnostic tests such as chest x-rays or laboratory values were ordered and completed. Interviews confirmed that the infection control logs were missing critical information required to assess infections according to McGeer's criteria. Medical record reviews revealed several deficiencies in the management of infections and antibiotic use. One resident with a stage four pressure wound was started on antibiotics without evidence of wound cultures or documentation supporting the presence of infection, despite meeting McGeer's criteria. Another resident with a UTI had urine cultures that did not meet the threshold for infection, and the facility could not provide documentation of the organism identified. A third resident was admitted with a UTI and started on antibiotics in the hospital, but the facility did not complete a McGeer's assessment to determine appropriateness upon admission. The facility's antibiotic stewardship policy lacked guidance on ensuring appropriateness before starting antibiotics and did not address proper documentation of infection-related information.