Failure to Document Supporting Labs for Antibiotic Stewardship
Penalty
Summary
The facility failed to complete antibiotic stewardship for two of four residents reviewed for unnecessary antibiotic use. According to facility policy, the Infection Preventionist (IP) is responsible for infection surveillance, tracking multidrug resistant organisms, and collecting and reviewing all supporting labs and tests for antibiotic usage. For both residents in question, one admitted with sepsis and the other with a bone infection, there were no supporting laboratory results or test documentation in their records to justify the prescribed antibiotic treatments. Interviews with the Resource Infection Preventionist confirmed that staff are expected to obtain appropriate diagnoses, start and stop dates for antibiotics, lab results, and other supporting data at the time of admission, especially for residents admitted with infections. However, a thorough review of the records for these two residents revealed that staff did not obtain the required lab results at admission, and the Infection Preventionist was unable to provide documentation to support the antibiotic treatments administered.