F0757

E

Unnecessary Antibiotic Use Without Proper UTI Assessment or Monitoring

San Diego, California Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents’ drug regimens were free from unnecessary drugs, specifically related to antibiotic use for suspected urinary tract infections (UTIs). For one resident with quadriplegia, immunodeficiency, and a suprapubic catheter, the facility used an Infection Screening Evaluation tool and infection surveillance list as part of its infection prevention and antibiotic stewardship program. On one occasion, this resident had an Infection Screening Evaluation score of 50 with acute dysuria, and a urine culture showing Gram positive cocci with a colony count of 50,000–90,000, leading to a physician order for Macrobid for a UTI. However, there was no supporting documentation that staff monitored UTI symptoms or side effects during the antibiotic course, despite the expectation that such monitoring occur during antibiotic therapy.

On a later occasion for the same resident, an Infection Screening Evaluation completed on a different date showed a score of zero, indicating no symptoms of infection. The prior urine culture still showed Gram positive cocci with a colony count of 50,000–90,000, yet the resident was prescribed Levofloxacin for a UTI and Methenamine Hippurate for infection prophylaxis. The Methenamine Hippurate order did not include a documented diagnosis that clearly supported infection prophylaxis and did not include a stop date. Again, there was no documentation of monitoring for UTI symptoms or side effects during the course of these antibiotics. The Infection Prevention (IP) nurse later acknowledged that the resident should have been monitored for signs and symptoms of UTI during antibiotic therapy and that the prophylactic antibiotic order required clarification and a defined duration.

Another resident with diabetes mellitus and moderate cognitive deficits was prescribed Ciprofloxacin for a suspected UTI based on confusion and a urinalysis with a colony count greater than 100,000 E. coli. The IP nurse stated that, according to McGeer criteria, residents without an indwelling catheter must exhibit two or more clinical symptoms in addition to a positive culture to support a UTI diagnosis, and that confusion alone did not meet the diagnostic criteria for initiating antibiotic therapy. For this resident, the Infection Screening Evaluation was not completed prior to starting the antibiotic, and there was no documented monitoring of UTI symptoms or side effects during the antibiotic course. The DON and facility policy indicated that staff were expected to follow appropriate clinical criteria, including McGeer criteria, and to avoid premature diagnostic conclusions, but these expectations were not met in the cases reviewed, resulting in antibiotics being initiated and continued without adequate indication, evaluation, or monitoring.

The facility’s written policy on urinary tract infection/bacteriuria stated that nurses should observe, document, and report signs and symptoms in detail and avoid premature diagnostic conclusions, and that physicians should carefully review persistent or recurrent UTIs before prescribing additional antibiotics, justifying any continuation or resumption of antibiotic treatment beyond an initial course. The DON stated that when a new antibiotic order is received, the IP nurse should complete the Infection Screening Evaluation and notify the physician if criteria for antibiotic therapy are not met, and that new onset nonspecific symptoms alone, such as change in mental status or decline in appetite, are not enough to diagnose a UTI. Despite these policies and stated expectations, the survey findings showed that antibiotics were ordered and administered without documented adherence to these criteria, without completion of the Infection Screening Evaluation in at least one case, and without documented monitoring of symptoms and side effects, constituting unnecessary drug use.