Failure to Conduct Required Antibiotic Time Outs for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement an Infection Prevention and Control Program that includes an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use, specifically the required antibiotic “time outs.” For one resident readmitted in June 2025 with diagnoses including pneumonia, acute respiratory disease, and dysphagia, physician orders directed the use of topical mupirocin 2% to the left great toe over two ordered time periods in January 2026. Record review did not show any evidence that an antibiotic time out or a review at day two or three was conducted for this mupirocin therapy. For another resident readmitted in June 2025 with diagnoses including pneumonia, acute respiratory failure, epilepsy, and repeated falls, physician orders included azithromycin 250 mg (two tablets once, then one tablet daily for four days) and ceftriaxone 1 gram daily over several days in December 2025. Additional record review failed to reveal documentation that an antibiotic time out or a day two or three review was completed for either the azithromycin or ceftriaxone. During an interview, the Director of Nursing Services was unable to provide evidence that antibiotic time outs or reviews had been completed and acknowledged being unfamiliar with the antibiotic timeout process.
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