Failure to Monitor and Document Antibiotic Use and Adverse Effects
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to implement its antibiotic stewardship, infection surveillance, and medication administration policies for one resident receiving antibiotics. The resident was admitted with diagnoses including an unspecified thoracic vertebra wedge compression fracture, essential hypertension, and generalized muscle weakness. A History and Physical dated 12/5/2025 documented that the resident had capacity to understand and make decisions, while the MDS dated the same day indicated severely impaired cognitive skills for daily decisions and dependence on staff for toileting, showering, and dressing. On 12/11/2025, a physician’s order directed cephalexin 500 mg by mouth twice daily for seven days for a UTI, and the resident’s care plan for history of UTI included interventions to administer medications as ordered and monitor for side effects, reporting them to the physician if noted. On 12/14/2025, the physician’s order was changed to ciprofloxacin 500 mg by mouth twice daily for seven days for UTI. The MAR for December 2025 showed that the resident received cephalexin from 12/11/2025 at 5 p.m. to 12/14/2025 at 5 p.m., and ciprofloxacin from 12/15/2025 at 9 a.m. to 12/21/2025 at 5 p.m. During interviews and concurrent record review on 1/6/2026, the Infection Preventionist stated that residents on antibiotics such as cephalexin and ciprofloxacin are to be monitored every shift for signs and symptoms of infection and any adverse reactions, with documentation in progress notes. The Infection Preventionist confirmed there was no documented antibiotic monitoring for adverse effects of cephalexin on 12/11/2025 and 12/12/2025 from 3 p.m. to 11 p.m., and no documented monitoring for adverse effects of ciprofloxacin on 12/15/2025 and 12/16/2025 from 7 a.m. to 3 p.m., and on 12/18/2025 from 3 p.m. to 11 p.m. RN 1 and the DON both stated that nurses are expected to monitor antibiotic use and adverse effects every shift and document in the medical record. Facility policies on Antibiotic Stewardship, Surveillance for Infections, and Administering Medications required monitoring and documentation of antibiotic use, signs and symptoms of infection, and any complaints, symptoms, and results related to medications, which were not followed during the identified shifts.
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