Failure to Maintain Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program as required by its own policies and regulatory standards. Review of facility policies indicated that all antibiotic use should be monitored and documented using an approved surveillance tracking form, with oversight by the Infection Preventionist (IP). However, documentation and clinical record reviews revealed that three out of five residents reviewed for antibiotic use were not properly tracked or reviewed. Specifically, one resident received multiple antibiotics for various infections, but the use and outcomes were not consistently documented on the surveillance logs. Another resident was prescribed prophylactic antibiotics for an indefinite period, and this was not reflected in the infection surveillance logs. A third resident was also treated prophylactically for suspected cellulitis without lab results, specific infection site, or follow-up notes, and this case was similarly omitted from the surveillance documentation. The residents involved had complex medical histories, including diagnoses such as multi-drug resistant organism infections, urinary tract infection, wound infection, diabetes, hypertension, dementia, and asthma. Despite receiving antibiotics, the required documentation and review processes were not followed, as evidenced by missing entries in the surveillance logs and lack of follow-up or outcome data. These omissions indicate that the facility did not adhere to its antibiotic stewardship protocols, resulting in incomplete monitoring and oversight of antibiotic use for these residents.