F0881

E

Failure to Monitor Antibiotic Adverse Effects Under Stewardship Program

Burbank, California Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its antibiotic stewardship policy by not monitoring a resident for adverse effects of levofloxacin during a prescribed treatment period. The resident was admitted with diagnoses including unspecified acute kidney failure, UTI, and generalized weakness, and was documented as cognitively intact and able to make decisions. An Interact Assessment Form dated 12/23/2025 showed an abnormal WBC of 15.2 and modest right lower lobe pneumonia, after which the physician was notified and ordered levofloxacin 500 mg orally once daily for seven days. The resident’s MAR confirmed administration of levofloxacin from 12/23/2025 to 12/29/2025. The resident’s care plan for pneumonia, initiated on 12/24/2025, included interventions to administer levofloxacin as ordered, monitor for adverse reactions, monitor for progress of status, notify the physician if the intervention was not effective, and monitor vital signs and infection-related symptoms.

During interviews and record review on 1/14/2026, the DON stated that residents receiving antibiotics are to be monitored for adverse effects every shift so that any adverse effects can be identified and the physician notified to change the antibiotic if needed. The DON acknowledged there was no documented monitoring for antibiotic adverse effects in the resident’s progress notes from 12/23/2025 to 12/29/2025, except for one entry on 12/26/2025 at 6:06 p.m., and stated that monitoring should have been done every shift. LVN 2 reported that nurses monitor residents on antibiotics for adverse reactions and document in the progress notes whether there was an adverse reaction or not. Review of the facility’s Antibiotic Stewardship policy, dated 12/2016 and last reviewed 8/15/2025, indicated that antibiotics will be prescribed and administered under the guidance of the facility’s antibiotic stewardship program and that training and education will emphasize the relationship between antibiotic use and gastrointestinal disorders, opportunistic infections, and medication interactions. The DON stated the policy did not specify the frequency of monitoring, but that nurses should monitor and document adverse effects of antibiotics every shift. The surveyors determined the facility failed to monitor this resident for adverse effects of levofloxacin from 12/23/2025 to 12/29/2025.