Failure to Implement Core Elements of Antibiotic Stewardship
Penalty
Summary
The facility failed to develop and implement the core elements of an antibiotic stewardship program as part of its infection prevention and control program for its 29 residents, 12 of whom were included in the sample. Review of the Infection Control Log for tracking and trending infections from March 2025 through February 2026 showed no documentation of organism identification, duration of prescribed antibiotics, or the specific infections being treated, and the facility was unable to provide this information when requested. The Infection Preventionist, who was also an administrative nurse, reported that she only tracked which residents were taking antibiotics in the EMR and confirmed she could not provide tracking and trending data for antibiotic use. She stated that floor nurses were expected to open the infection document for tracking but were not completing the form, leaving her with only records of antibiotics that residents had taken for infections, without the additional required details. This practice did not align with the facility’s Infection Preventionist policy, which assigned responsibility for effective direction, management, and operation of the infection prevention program, including use of evidence-based practices and compliance with CMS and state regulatory requirements. No additional resident-specific medical histories or conditions at the time of the deficiency were provided in the report.
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