F0881

E

Failure to Maintain an Effective Antibiotic Stewardship Program

West Bloomfield, Michigan Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The facility failed to develop and implement an antibiotic stewardship program that promotes appropriate antibiotic use and includes a system of monitoring. During an interview, the ICP stated that their role included ensuring residents met McGeer's criteria for antibiotic use, confirming staff followed protocols and procedures, educating staff on infection control policies, and using audits and an infection screening tool to determine if residents met criteria for antibiotics. The ICP reported they began the position in November 2025 and were hired specifically for infection control.

However, the ICP explained that due to staffing shortages they were frequently assigned to work as a floor nurse and could only perform infection control duties when time allowed. Review of the infection control books showed that requested information, including specific resident lab results, clinicians' rationale for antibiotic use, and documentation of McGeer's criteria supporting prescribed antibiotics, was not available. The ICP acknowledged that the program was not compliant except for one month when staffing was adequate. The ICP also reported that they had requested additional help and training from corporate staff but were denied, and that they had functioned more as a floor nurse than an ICP. When the antibiotic stewardship policy was requested, no additional information was provided.