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F0881
F

Failure to Implement Antibiotic Stewardship and Infection Control Tracking

Lawrence, Kansas Survey Completed on 12-03-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement the core elements of an antibiotic stewardship program as part of its infection prevention and control efforts. Specifically, the facility was unable to provide infection control logs for several months, which should have included tracking and trending of infections, identification of possible outbreaks, and documentation of antibiotic administration. The infection control surveillance lacked consistent identification of infections and proper documentation. The administrative nurse responsible for antibiotic tracking admitted that monthly tracking of antibiotic use had not been completed since May 2025, and review of physician-ordered antibiotics for appropriate criteria was only done for self-education, not as part of a systematic program. The facility's policy required education on proper antibiotic use and resistance, but there was no evidence this was being consistently implemented.

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