Failure to Follow Antibiotic Stewardship Protocol for Ocular Infection
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship protocol for one resident who was prescribed an antibiotic without meeting the required McGeer criteria. The resident, who had a history of schizophrenia, depression, and seizures, was dependent on nursing staff for most activities of daily living and lacked the capacity to make decisions. The resident was prescribed and administered Gentamicin Sulfate Solution for a right eye infection, despite only presenting with symptoms of a swollen and teary eye and without a laboratory culture being performed to confirm the infection. Interviews with facility staff, including the Infection Preventionist Nurse and the Director of Nursing, confirmed that the Surveillance Data Collection Form did not indicate a culture was done and that the resident did not meet the McGeer criteria for antibiotic use. The facility's policy required antibiotics to be prescribed and administered under the guidance of the antibiotic stewardship program, which was not followed in this case.