Antibiotic Order Lacked Required Duration Under Facility ASP Policy
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program (ASP) requirements when ordering and administering an antibiotic medication for Resident 26. The facility’s undated Antibiotic Stewardship Policy stated that all antibiotic orders must include dose, duration, route, and indication, and that these orders would be tracked and kept in the medical record. Record review of Resident 26’s March 2026 Treatment Administration Record (TAR) showed an order for Tobradexame suspension, a steroid/antibiotic combination, to be instilled as one drop to both eyes four times daily as needed for blepharitis, with a start date of 08/25/25 but no stop date documented. The TAR further showed that the resident received the eye drops on March 4 and March 5, 2026, for red eyes, despite the absence of a documented duration for the antibiotic therapy. In an interview, the DON confirmed that all antibiotic orders were required to have a duration and acknowledged that Resident 26’s Tobradexame order did not include this required element. This deficiency occurred in the context of a facility census of 27 residents and was identified through record review and staff interview, demonstrating that the specific antibiotic order for Resident 26 was not written in accordance with the facility’s established ASP policy regarding inclusion of treatment duration.
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