Failure to Ensure Drug Regimen Free from Unnecessary Antibiotics
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically by administering Keflex as a prophylactic antibiotic without adequate indication. The resident, a female with a history of urinary tract infections (UTIs) and moderate cognitive impairment, was prescribed Keflex 500mg at bedtime for prevention, despite not having current symptoms or a documented infection at the time. The resident's care plan did not include entries related to UTIs or antibiotic use, and her medical records showed she had been diagnosed with UTIs on three separate occasions, each treated with different antibiotics based on culture results. Interviews with facility staff revealed gaps in monitoring and documentation practices. The Assistant Director of Nursing/Infection Preventionist (ADON IP) stated that the only form used for antibiotics was the infection surveillance report and that there was no other system in place to document symptoms or track infections. The Director of Nursing (DON) indicated that the family had requested ongoing antibiotics and believed the pharmacist was reviewing antibiotic use, but acknowledged the absence of a standardized form for tracking UTI symptoms. The Medical Director and Pharmacy Consultant both confirmed that prophylactic antibiotic use was not being routinely reviewed or monitored, and recommendations regarding ongoing antibiotic therapy were not being communicated to the prescribing physician. Facility policies referenced the use of McGeer Criteria for infection surveillance and outlined expectations for antibiotic stewardship, including assessment, documentation of indication, dose, and duration, and periodic review of antibiotic use. However, these protocols were not followed in practice, as evidenced by the lack of care planning, inadequate monitoring, and absence of documentation supporting the ongoing use of prophylactic antibiotics for the resident.