Failure to Monitor and Document Antibiotic Use in Infection Control Program
Penalty
Summary
The facility failed to establish and implement an effective Infection Prevention and Control Program (IPCP) that included an Antibiotic Stewardship Program with protocols and a system to monitor antibiotic use. The facility's policy on antibiotic stewardship, last reviewed in 2012, required the Infection Preventionist (IP) to conduct infection surveillance, track multidrug-resistant organisms (MDROs), and collect data on antibiotic use, including whether appropriate tests such as cultures were obtained before starting antibiotics. However, a review of the infection surveillance line lists from January to May 2025 revealed that a resident who developed a urinary tract infection (UTI) in March 2025 and was started on antibiotics was not included in the March infection line list. The resident's condition worsened, leading to hospitalization and a change in antibiotic therapy. During interviews, the Assistant Director of Nursing (ADON) stated that McGeer's criteria were used to determine the need for antibiotics but admitted that documentation of whether the criteria were met was not maintained. The Director of Nursing (DON) acknowledged that the resident with the UTI had been missed on the infection line list and was unsure how this occurred, further noting that the infection line lists needed to be revamped. These findings demonstrate that the facility did not ensure proper infection surveillance, documentation, and monitoring of antibiotic use as required by their own policy and regulatory standards.