Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program as required, specifically by not performing antibiotic time out assessments for a resident who had multiple courses of antibiotics. The resident, who had diagnoses including dementia, pressure ulcers, a history of urinary tract infections, and cellulitis of the right great toe, was prescribed antibiotics on several occasions for various infections such as urinary tract infections, clostridium difficile, cellulitis, toe infection, increased white blood count, conjunctivitis, and osteomyelitis. Despite these multiple antibiotic treatments, the medical record review revealed that antibiotic time out assessments were not completed on several dates when antibiotics were initiated. An interview with the Assistant Director of Nursing confirmed that staff did not perform the required antibiotic time out assessments for the resident on the specified dates. The facility's policy stated that the infection prevention and control nurse was responsible for tracking all antibiotic starts and monitoring adherence to criteria during infection management. The lack of these assessments was verified and acknowledged by facility staff, representing a failure to follow the established antibiotic stewardship program.