Failure to Monitor and Document Antibiotic Use and Incomplete Infection Surveillance
Penalty
Summary
The facility failed to implement its antibiotic stewardship policy for two of three sampled residents by not monitoring antibiotic use, signs and symptoms, side effects, or adverse reactions. For one resident admitted with diagnoses including sepsis, acute appendicitis with perforation, localized peritonitis, and gangrene with abscess, there was no documented monitoring for antibiotic use during five nursing shifts while the resident was receiving intravenous ertapenem. The Infection Preventionist confirmed that monitoring and documentation were missing for these periods, which are necessary to assess for adverse reactions and effectiveness of the antibiotic therapy. Another resident, admitted with acute respiratory failure with hypoxia, pneumonia, and dementia, was prescribed oral Zyvox for pneumonia. The Medication Administration Record showed the resident received the antibiotic as ordered, but there was no documentation of monitoring for antibiotic use on two specific shifts. The Infection Preventionist and Director of Staff Development both stated that residents on antibiotics should be monitored for signs and symptoms and side effects every shift, and the Director of Nursing confirmed that this monitoring and documentation did not occur for these residents. Additionally, the facility's Infection Prevention and Control Surveillance Log for the relevant month was incomplete, with missing entries for signs and symptoms of infection and the date antibiotics were completed. The Infection Preventionist and Director of Nursing both acknowledged that the log should have included this information to track infection, monitor treatment, and determine antibiotic effectiveness. The facility's policy required the Infection Preventionist to track and report antibiotic stewardship processes, but this was not done as required.