Failure to Monitor and Review Antibiotic Use
Penalty
Summary
The facility failed to establish and implement an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program with protocols and a system to monitor antibiotic use. Specifically, for three residents who were prescribed antibiotics for various conditions—including an infection of the great toe, a surgical incision, and pneumonia—there was no evidence in the medical records that an antibiotic 'time out' or review was conducted within 48 to 72 hours after the initiation of antibiotic therapy, as recommended by the CDC's Core Elements of Antibiotic Stewardship for Nursing Homes. Record reviews for these residents showed that antibiotics such as doxycycline and cephalexin were administered, but documentation of a clinical review to assess the appropriateness of the antibiotic, its dose, route, or duration was absent. During an interview, the Infection Preventionist confirmed that no antibiotic timeouts were completed for these residents and further disclosed that, during her leave of absence, there was no designated staff member responsible for completing these reviews.