F0881

F

Failure to Maintain Antibiotic Stewardship and Infection Surveillance

Merkel, Texas Survey Completed on 02-16-2026

Penalty

Fine: $204,535

Summary

The deficiency involves the facility’s failure to implement and maintain an infection prevention and control program that included an antibiotic stewardship component with antibiotic use protocols and a system to monitor antibiotic use for three consecutive months. Record review showed there was no infection tracking log or other evidence of an antibiotic stewardship program for December 2025, January 2026, and February 2026. The facility’s written policy, revised in September 2017, stated that surveillance of infections was intended to identify individual cases and trends of significant organisms and healthcare-associated infections, using standard definitions and including infections such as pneumonia, UTIs, C. difficile, and pathogens associated with serious outbreaks.

During interviews, the ADON reported that she had previously performed infection prevention tasks, including tracking infections and maintaining a binder of residents who received antibiotics, but she was no longer responsible for tracking and trending infections after a previous DON was hired. She stated the previous DON’s last day was in mid-December 2025 and could not provide any evidence of antibiotic stewardship activities after her own prior tracking efforts. The AIT confirmed that both the previous and new DON had completed infection preventionist training and were designated as the facility’s IPs, but she was unable to provide any infection tracking or trending documentation for December 2025, January 2026, or the current month. The newly hired DON stated that the survey date was her first day working on the floor and that she was still in training, having only completed online training beforehand, and there was no documentation available to show that infection surveillance or antibiotic use monitoring had been conducted during the cited months.