Failure to Clarify and Monitor Antibiotic Therapy Duration
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications, specifically regarding the continued use of an antibiotic for a chronic lower leg skin infection. The resident, who had a history of urinary tract infections and skin infection, was started on an antibiotic with a physician order that directed staff to follow up with the provider regarding the infection. However, the order did not specify a stop date or duration for the antibiotic therapy. A pharmacy medication review identified the missing stop date and duration, noting the increased risk associated with prolonged use, and recommended that the intended duration or stop date be documented. Despite this, there was no evidence that the facility provided this information or clarified the order with the provider. Medication Administration Records showed the resident received the antibiotic twice daily for nearly two months without documented reassessment or clarification of the ongoing need. Progress notes did not indicate that the provider was notified to address the missing stop date or duration. Interviews with the Infection Preventionist revealed a lack of awareness regarding the resident’s ongoing antibiotic therapy and a failure to follow up as required by the physician’s order. The antibiotic usage was also not documented on the care plan, and both nursing staff and the Infection Preventionist did not ensure appropriate follow-up with the provider.