Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish and maintain an effective Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. Specifically, for three residents reviewed for antibiotic use, physician orders for antibiotics did not include the required indication for use, as mandated by both CDC guidelines and the facility's own policy. The residents involved had diagnoses such as acute bronchiolitis due to respiratory syncytial virus, aftercare following surgical amputation, and pneumonia. In each case, the physician's orders for antibiotics lacked documentation of the clinical indication, which was confirmed during interviews with the Director of Nursing Services (DNS), who acknowledged the omission. Additionally, the facility did not have an active Antibiotic Stewardship Team as required by its policy. The policy specified that such a team should meet regularly, maintain meeting minutes, and analyze the efficacy of the program annually. However, during interviews, the DNS confirmed that the facility did not have an antibiotic stewardship team in place, nor were there any meeting minutes available, despite the policy's requirements.