Failure to Maintain Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program as required by both CDC guidelines and its own policies. Over a review period of ten months, the facility did not implement antibiotic use protocols, did not conduct complete reviews of antibiotic orders to determine appropriateness, and lacked a system to effectively monitor antibiotic usage and track symptoms. The facility's antimicrobial stewardship policy required documentation of dose, duration, route, and indication for every antimicrobial prescription, as well as monthly reviews for compliance and appropriateness, but these actions were not consistently performed. A review of facility documentation and pharmacy order reports revealed discrepancies between the number of antibiotic prescriptions recorded and those tracked by the facility. For each month reviewed, the number of residents receiving antibiotics according to pharmacy records exceeded the number tracked by the facility's stewardship program. For example, in January, pharmacy records showed 15 residents with antibiotic orders, but the facility only completed 10 infection reviews over a six-month period, indicating incomplete monitoring and tracking. Interviews with facility staff, including the Director of Nursing, confirmed that the antibiotic stewardship program did not include necessary protocols, comprehensive review of antibiotic orders, or effective monitoring systems. The lack of integration of dispensing and consultant pharmacists into the clinical care team further contributed to the deficiency, as did the absence of specific interventions to address inappropriate antibiotic use. These findings were cited as violations of state regulations regarding resident care policies and nursing services.