Failure to Follow Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Program standards for monitoring and surveillance of antibiotic use for one resident. According to the facility's policy, nurses are required to utilize infection criteria protocols to determine the necessity of antibiotics, document the rationale for antibiotic prescriptions, and monitor for effectiveness, side effects, and adverse consequences. In the case reviewed, a resident with dementia and at risk for skin integrity issues was prescribed an oral antibiotic for cellulitis of the left second toe. The antibiotic prescribed was noted to be outside the recommended dose and frequency, yet there was no assessment indicating that infection criteria protocols were completed or reviewed by the provider before or after the prescription. Additionally, the required 'antibiotic time out'—a review of the appropriateness of the antibiotic 24-48 hours after initiation—was not performed. The provider was not notified that the prescribed antibiotic was outside the recommended dosing guidelines, nor was there documentation that the provider was made aware of whether infection criteria were met. The facility's Infection Preventionist confirmed that these antibiotic stewardship processes were not followed for this resident.