Failure to Conduct Effective Antibiotic Surveillance Program
Penalty
Summary
The facility failed to ensure an effective antibiotic surveillance program was conducted for 11 out of 12 residents who were prescribed antibiotics, as required by the facility's policy and procedure. During an unannounced visit, the Infection Preventionist (IP) reported that antibiotic use was monitored by printing a daily list of residents on antibiotics and following up with licensed nurses to confirm administration and check for adverse effects. However, upon review of documentation, it was found that antibiotic surveillance assessments, which should include a review of the resident's symptoms and appropriateness of antibiotic use, were not completed for residents on antibiotics from August 2024 to January 2025. The IP was unable to provide surveillance documentation for this period, confirming that the required monitoring was not performed. The facility's policy outlined that surveillance tools, culture reports, sensitivity data, and antibiotic usage reviews should be included in infection prevention and control activities. Despite this, the lack of documented surveillance meant that the appropriateness of antibiotic use for residents with various infections, including UTIs, sepsis, pneumonia, and infections at other sites, was not evaluated according to policy. This lapse was acknowledged by the IP, who stated that the absence of infection surveillance and antibiotic stewardship placed residents at risk for improper antibiotic use and ineffective infection control.