F0757

E

Failure to Ensure Antibiotic Regimens Were Free From Unnecessary Drugs

Morrison, Illinois Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents’ drug regimens were free from unnecessary antibiotics, contrary to its own antibiotic stewardship policy requiring an indication and stop date for all antibiotic orders. For one resident, a physician ordered Macrobid 100 mg daily for a UTI, but the order lacked a stop date, and the DON/Infection Preventionist (IP) acknowledged the resident did not have an acute UTI at the time and that no repeat urinalysis was done before starting the medication. The DON/IP further stated she had not reassessed this resident’s continued need for Macrobid since it was started.

Additional residents were maintained on prophylactic antibiotics without appropriate assessment, diagnosis, or stop dates. One resident was prescribed daily Cephalexin for prophylaxis by hospice due to a history of UTIs, with no associated diagnosis, no stop date, and no urinalysis or culture obtained by the facility before starting the medication; the DON/IP had never discussed this order or its ongoing need with hospice. Another resident received Bactrim twice weekly for prophylaxis based on a personal history of UTIs and the resident’s desire to remain on it, despite never having an acute UTI diagnosis or urinalysis while in the facility, and without any discussion of continued use with the nurse practitioner. A fourth resident was admitted from a hospital on Nitrofurantoin for UTI prevention, and the facility simply continued the order due to a history of UTIs, without obtaining a urinalysis or consulting the nurse practitioner about the need to continue the antibiotic. These practices conflicted with the facility’s written antibiotic stewardship policy requiring drug name, dose, frequency, start and stop dates, route, and indications for use on all antibiotic orders.