Failure to Monitor and Appropriately Steward Antibiotic Use
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective antibiotic stewardship program and to monitor antibiotic use. For the period from 02/01/26 through 02/24/26, the facility could not provide antibiotic and infection surveillance logs, demonstrating that infections and antibiotic use were not tracked during that month. As a result, there was no evidence that staff identified commonalities, patterns, or trends in infections or antibiotic usage, nor documentation of how determinations were made regarding the appropriateness of prescribed antibiotics. An administrative nurse stated that the facility used McGeer’s Criteria to determine appropriate antibiotic use but verified there was no evidence of antibiotic tracking, trending, or documentation supporting decisions about antibiotic prescriptions. The deficiency also includes an individual case in which a resident received an antibiotic for a urinary tract infection (UTI) without confirmation of infection by culture. An incident note showed that the resident’s physician ordered a urinalysis (UA) with culture and sensitivity, and a progress note documented preliminary positive UA results with culture and sensitivity pending. A subsequent progress note recorded that the UA results led to an order for Nitrofurantoin 100 mg by mouth twice daily for five days for UTI. A licensed nurse reported that providers generally would not start an antibiotic without a culture and sensitivity report and that the facility used McGeer’s Criteria and opened an Antibiotic Stewardship Assessment. The nurse contacted the lab and obtained the final culture and sensitivity report, which was negative for UTI, even though the resident had already been started on antibiotics two days earlier. An administrative nurse confirmed that the resident should not have received antibiotics for a UTI when the final culture report was negative and acknowledged that antibiotic stewardship should be tracked and monitored for trends, patterns, and appropriate use, consistent with the facility’s Antibiotic Stewardship policy dated 02/04/25.
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