Failure to Monitor Antibiotic Use and Side Effects
Penalty
Summary
The facility failed to implement its antibiotic stewardship and infection prevention and control policies for one resident by not monitoring the use and adverse effects of azithromycin, an antibiotic prescribed for pneumonia. The resident, who had a history of hereditary and idiopathic neuropathy, a history of falls, and severely impaired cognitive skills, was admitted with significant care needs and lacked the capacity to make decisions. The resident received azithromycin over a three-day period, as documented in the Medication Administration Record. Despite facility policy requiring monitoring for antibiotic side effects every shift, there was no documentation in the resident's progress notes indicating that such monitoring occurred during the period the antibiotic was administered. Both the Infection Preventionist and the Director of Nursing confirmed during interviews that nurses are expected to monitor and document for side effects and adverse reactions to antibiotics every shift, but acknowledged that this was not done for this resident. A review of the facility's policies showed that antibiotic usage and outcomes are to be documented using an approved surveillance tracking form, and that all clinical infections treated with antibiotics should be reviewed by the Infection Preventionist or designee. The lack of documentation and monitoring for this resident was inconsistent with these established policies and procedures.