Failure to Include Resident on Antibiotic Stewardship Line List
Penalty
Summary
A deficiency occurred when the facility failed to include one of two residents reviewed for antibiotic stewardship on the facility's antibiotic line listing, as required by facility policy. The resident in question was admitted with diagnoses including atrial fibrillation and dementia, and had been prescribed intravenous (IV) Ceftriaxone for presumptive septic arthritis following a hospital stay. The resident's medication administration record confirmed that the antibiotic was administered over a period of several days. However, the resident was not added to the facility's antibiotic stewardship line list, which is used to monitor and track antibiotic use and infections as part of the infection prevention and control program. Interviews with the Infection Preventionist revealed that all residents receiving antibiotics, including those whose antibiotic regimens were initiated in the hospital, should be included on the line list per facility protocol. Upon review of the antibiotic stewardship binder, it was confirmed that the resident was not listed, and the Infection Preventionist acknowledged this omission, stating that the resident should have been included regardless of the presumptive nature of the antibiotic use. The Director of Nursing was also informed of this oversight.