Failure to Monitor and Document Adverse Effects of Antibiotic Therapy
Penalty
Summary
The facility failed to implement and follow its Infection Prevention and Control Program and Antibiotic Stewardship Program for multiple residents receiving antibiotic therapy. Specifically, staff did not monitor or document monitoring for adverse effects of antibiotics for several residents, despite facility policies and care plans requiring such monitoring every shift during and after antibiotic administration. For example, one resident with pneumonia received levofloxacin for five days without any documented monitoring for side effects, and another resident with pneumonia received amoxicillin-potassium clavulanate for seven days with no documentation of monitoring for adverse reactions, even though care plans specified this intervention. Additional residents were affected by similar lapses. One resident with a history of ESBL resistance and severe septic shock received Avycaz intravenously, but there was no documentation of monitoring for adverse effects for fifteen shifts. Another resident with pneumonia received amoxicillin via gastrostomy tube, but staff failed to document monitoring for adverse effects for nine shifts. Two residents with UTIs who received cefdinir also lacked documentation of monitoring for adverse effects during and after antibiotic therapy, except for isolated instances. In each case, staff interviews confirmed that monitoring should have occurred and been documented, but it was not done as required by facility policy. Facility policies reviewed during the survey clearly outlined the need for monitoring and documenting adverse effects of antibiotics, including the use of an antibiotic surveillance tracking form to record relevant data such as start and stop dates, adverse events, and outcomes. Despite these policies, the survey found consistent failures in both monitoring and documentation across multiple residents and antibiotic regimens. Staff and leadership interviews acknowledged these deficiencies and the lack of adherence to established protocols.