Failure to Implement Antibiotic Stewardship for Suspected UTIs
Penalty
Summary
The deficiency involves the facility’s failure to implement its antibiotic stewardship program to ensure appropriate use of antibiotics, specifically related to urinary tract infection (UTI) management. For one resident admitted in December 2024 and readmitted in September 2025 with diagnoses including heart failure, COPD, and diabetes mellitus, record review showed no documentation of any UTI signs or symptoms in the medical record. Despite this, the infection control log for January 2026 listed the resident as having acquired an in-house UTI and receiving antibiotics from January 27, 2026, to February 3, 2026, and indicated that McGeer’s criteria were met. The DON confirmed there was no documentation of UTI signs or symptoms, and although a urinalysis was ordered on January 19, 2026, there was no documentation of signs and symptoms or a completed McGeer’s assessment for UTI. A second resident, admitted in August 2023 and readmitted in March 2024 with diagnoses including chronic kidney disease, major depressive disorder, and anxiety disorder, similarly had no documentation of UTI signs or symptoms in the medical record. The quarterly MDS showed this resident had intact cognition and was dependent on staff for ADLs. The facility’s infection control log for February 2026 recorded that this resident acquired an in-house UTI and was on antibiotics from February 1, 2026, to February 6, 2026, and again indicated that McGeer’s criteria were met. The DON verified there was no documentation of UTI signs or symptoms and no McGeer’s assessment completed for this UTI. Review of the facility’s undated Antibiotic Stewardship Program policy showed that the infection control nurse or designee was responsible for infection control line listing and review of antibiotic utilization to ensure appropriate prescribing and use of antibiotics, which was not carried out as required in these cases.
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