F0881

F

Failure to Implement Antibiotic Stewardship Program

Clemmons, North Carolina Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The facility failed to implement its antibiotic stewardship program as required by its own policy, which had the potential to affect all 87 residents. The written policy, effective 12/2025, stated that the Antibiotic Stewardship Program was intended to optimize the infection prevention program by guiding treatment of infections and reducing adverse events associated with antibiotic use. The policy specified that the Infection Preventionist would use expertise and data to track antibiotic starts, monitor adherence to evidence-based criteria for evaluation and management of infections, and review antibiotic resistance patterns in the facility. Pharmacy services produced antibiotic use tracking sheets showing that 25 residents were on antibiotics in November 2025, 37 in December 2025, and 40 in January 2026, but there was no evidence that these data were being used within a functioning stewardship program.

During interviews, the current DON, who had been in the role since the end of December 2025 and was responsible for the Infection Prevention and Control program, stated she was in the process of getting the Antibiotic Stewardship Program in place but was unable to locate any information from prior months. When asked about monitoring and tracking infections, she reported she could not find any information for the prior months. The previous DON, who served from 9/2025 to 12/2025, confirmed by telephone that she did not have an antibiotic stewardship program in place and that no one had provided her with guidance or instructions. The Administrator stated she expected the antibiotic stewardship program to be in place per protocol and reported that infections were discussed during QAPI meetings, but there was no indication that a formal antibiotic stewardship program, as described in the facility policy, had been implemented.