Lack of Indication and Duration for Antibiotic Bladder Irrigation Order
Penalty
Summary
Surveyors identified a deficiency related to unnecessary medications when reviewing facility policies, medical records, and staff interviews. The facility’s Physician/Providers Orders Policy required each medication order to include the resident’s name, drug name and strength, indication or diagnosis, dosage, frequency, route, duration, and any required monitoring parameters. The Unnecessary Medications Policy required that each resident’s medication regimen be free from unnecessary medications, including those prescribed without adequate indications for use or without appropriate monitoring. For one resident admitted with multiple diagnoses including lumbar spinal stenosis and neurogenic bladder, a physician order dated 9/22/25 prescribed Gentamicin Sulfate irrigation, 400 mg every day and night shift, with instructions to inject 60 cc of solution into the bladder via Foley catheter, clamp for 30 minutes, then unclamp. This order did not document an adequate indication or diagnosis for the Gentamicin use and listed the duration as indefinite. During an interview on 3/3/26 at 1:37 PM, the ACNO acknowledged that the Gentamicin order should have included an indication for use and a duration but did not, confirming noncompliance with the facility’s own policies. The report stated this failure had the potential to cause significant harm if the resident were to develop antimicrobial resistance or toxicity.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.