F0881

E

Failure to Implement Effective Antibiotic Stewardship and Infection Tracking

Clearwater, Florida Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement an effective antibiotic stewardship program, specifically in tracking infections and ensuring antibiotic use met established infection criteria. Review of the December 2025 Infection and Antibiotic Tracking Tool showed a resident identified as having a UTI with symptoms documented only as "urinary tract symptoms" and leukocytosis. Although a urine test was obtained, there was no documentation of WBC count, colony count, or culture results, and the urinalysis was negative, yet the resident received a 7‑day course of Ceftriaxone. The tracking tool did not specify which urinary symptoms were present.

In January 2026, the Infection and Antibiotic Tracking Tool was found to be incomplete, with symptoms not listed and no indication whether cultures or tests had been obtained for five of nineteen facility-acquired conditions treated with antibiotics. One resident was treated with Nitrofurantoin for a facility-acquired UTI, but the tool did not document symptoms, whether testing was obtained, or test results. Progress notes showed this resident reported not feeling like herself, had an order for a urinalysis, and later had a urine culture with >100,000 CFU of E. coli and many bacteria, but there was no evidence that infection surveillance criteria were completed to determine the necessity of antibiotic use.

Another resident was treated with doxycycline for a facility-acquired skin and soft tissue infection of a lower extremity wound, but the tracking tool did not document symptoms, test or culture results, or whether any tests were obtained. An SBAR noted a new skin wound or ulcer with no observed changes in skin and no applicable pain, and the infection surveillance criteria for cellulitis showed that the condition did not meet the required criteria for infection (no pus and only three of four required signs/symptoms). Despite this, the resident received antibiotics. Interviews with the IP and DON confirmed that line listings were incomplete, surveillance criteria were not consistently completed, antibiotic tracking was not reliably performed (especially for hospital-initiated antibiotics), and that the facility’s policies did not address completion of tracking and surveillance tools, even though the infection control program policy required surveillance data and antibiotic usage reviews as part of antibiotic stewardship.