Failure to Utilize Infection Assessment Screening for Antibiotic Stewardship
Penalty
Summary
The facility failed to utilize an infection assessment screening to determine the necessity of antibiotic use for two of five sampled residents reviewed for antibiotic stewardship. According to the infection prevention and control program policy, an antibiotic stewardship program, including protocols and a system to monitor antibiotic use, was to be implemented. However, record review showed that one resident received zithromax for an upper respiratory infection and another received azithromycin and later doxycycline for a skin infection, with no laboratory results or infection assessment screenings documented in their clinical records for these antibiotic treatments. Interviews with the DON and director of clinical services revealed that the facility claimed to use the McGreer and Loeb screening tools for antibiotic stewardship, with infection screening evaluations supposedly located under assessments in the clinical record. Despite these claims, the last documented infection screening evaluation for one resident was several months prior to the antibiotic administration, and no screening tools were found for the relevant infection episodes. The DON confirmed that antibiotic appropriateness was determined based on physician orders, but there was no evidence of the required infection assessment screenings being completed at the time antibiotics were prescribed.