Failure to Maintain an Active Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish and maintain an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. The written Antibiotic Stewardship policy, dated 7/1/25, stated that the facility would implement an antibiotic stewardship program as part of its overall infection prevention and control program, with the purpose of optimizing treatment of infections and reducing adverse events associated with antibiotic use. The policy identified the Medical Director, DON, IPC Nurse, and Consultant Pharmacist as leaders of the program, with support from the Administrator and governing officials. However, during an interview, the Administrator reported that the antibiotic stewardship program had not been updated since March 2025, that the IPC Nurse had recently quit, and that the facility had only just restarted the program on 1/22/26, despite the Administrator’s expectation that the program should have been in place for the facility’s census of 91 residents. No specific residents, their medical histories, or clinical conditions at the time of the deficiency were described in the report, and no resident-specific antibiotic use data or monitoring activities were documented. The deficiency is based on the lack of an active, updated antibiotic stewardship program and the absence of established antibiotic use protocols and a monitoring system as required by the facility’s own policy.
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