Failure to Follow Antibiotic Stewardship Protocols for UTI Treatment
Penalty
Summary
The facility failed to follow its own standards of practice for antibiotic stewardship by not ensuring that a culture and sensitivity test was performed before prescribing antibiotics for a resident diagnosed with an acute urinary tract infection. The resident, who had a medical history including chronic kidney disease, Type 2 diabetes mellitus, and urge incontinence, experienced symptoms such as pain, itching, and burning in the vaginal area. After being seen in the emergency department, the resident was diagnosed with a urinary tract infection and prescribed ciprofloxacin without evidence of susceptibility testing to confirm the appropriateness of the antibiotic. Facility policy requires that antibiotic use be based on clinical standards, including evaluation of symptoms and, when necessary, obtaining further documentation to support the treatment plan. The Infection Preventionist or designee is responsible for reviewing antibiotic orders, which includes ensuring the necessity and appropriateness of the treatment. During the survey, the Vice President of Clinical Operations confirmed that there was no culture and sensitivity test documented in the resident's electronic health record, acknowledging that such testing should have been completed to ensure the correct antibiotic was prescribed.