Failure to Ensure Appropriate Antibiotic Stewardship and Documentation
Penalty
Summary
The facility failed to promote antibiotic stewardship by not ensuring the appropriate use of antibiotic therapy and not providing written rationale from the provider when an antibiotic was used outside of established criteria. For one resident, there was no documentation that established and accepted criteria, such as the McGeer or CDC criteria, were used to determine if her urinary tract infection (UTI) met the requirements for antibiotic use. Additionally, the resident was receiving a prophylactic antibiotic (Keflex) without written justification for its use, and her care plan did not include entries related to UTIs or antibiotic use. Record reviews showed that the resident had been diagnosed with UTIs on three separate occasions, with symptoms documented as altered mental status, increased confusion, and not feeling well, but without comprehensive symptom tracking or documentation of other required criteria. The infection surveillance reports did not consistently document all necessary symptoms, and the facility did not have a standardized form to track symptoms at the onset of UTI symptoms. Interviews with staff revealed that there was no system in place to track symptoms, and the only form used was the infection surveillance report. The pharmacy consultant was not reviewing residents on prophylactic antibiotics or sending recommendations to the medical director, and the pharmacist's review of antibiotics was inconsistent and did not include ongoing prophylactic use. Facility policies referenced the use of McGeer criteria and the importance of antibiotic stewardship, including assessment using standardized tools, specifying dose, duration, and indication, and periodic review of antibiotic prescriptions. However, these policies were not followed in practice, as evidenced by the lack of documentation, symptom tracking, and oversight of antibiotic use for the resident in question.