F0881

D

Failure to Monitor Antibiotic Use Resulting in Extra Vancomycin Dose

Providence, Rhode Island Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The facility failed to establish and implement an Infection Prevention and Control Program (IPCP) that included an effective antibiotic stewardship program with protocols and a system to monitor antibiotic use. The facility’s own ANTIBIOTIC STEWARDSHIP policy, last revised in September 2025, required that antibiotics be prescribed and administered under the guidance of the stewardship program and that prescribers provide complete antibiotic orders, including duration of treatment, start and stop dates, and number of days of therapy. A resident with diagnoses including sepsis and bacteremia, who had recently completed a course of IV antibiotics for a UTI, was ordered vancomycin 1 gram every 12 hours for 12 days beginning on 12/2/2025, for a total of 24 doses. An Antibiotic Time Out assessment was completed by the Infection Preventionist (IP) for this vancomycin order and reviewed with the resident’s Nurse Practitioner.

Record review showed that, despite the clear order for 24 doses, the December 2025 Medication Administration Record documented that the resident received 25 doses of vancomycin. During an interview, the Nurse Practitioner stated she was unaware that the resident had received an extra dose. In a separate interview, the IP, in the presence of the Director of Nursing Services, acknowledged completing the antibiotic time out for the vancomycin but failed to identify that the resident was scheduled to receive an additional, non-ordered dose. These actions and omissions demonstrated that the facility did not effectively monitor antibiotic use or ensure that the resident received only the prescribed number of antibiotic doses, as required by the facility’s antibiotic stewardship policy and IPCP requirements.