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F0881
F

Failure to Implement Antibiotic Stewardship Program

Pittsburgh, Pennsylvania Survey Completed on 09-12-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement an antibiotic stewardship program for eleven consecutive months, from September 2024 through August 2025. Review of the facility's infection control policies indicated that the antibiotic stewardship program was intended to improve antibiotic use and was to be managed by the Infection Preventionist in collaboration with the medical director, pharmacist, nursing, and administrative leadership. However, infection control surveillance records for the specified period lacked documentation of any antibiotic monitoring. During interviews, the Infection Preventionist LPN confirmed that antibiotic monitoring was not completed for the majority of the year and was unable to provide further information about the stewardship program, deferring to the Director of Nursing. The Director of Nursing also confirmed the failure to implement the program during this period.

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