A resident receiving IV meropenem for an abdominal abscess after surgery missed 27 ordered doses when the antibiotic was stopped without explanation and later restarted after the ID office called the facility. The resident also did not receive ordered weekly CBC, CMP, and CRP labs while on IV antibiotics, and the DON stated the labs had not been completed until the ID office reported they were missing.
The facility failed to maintain oversight of antibiotic use and infection criteria. A review of the infection surveillance program showed multiple infections listed as unknown, infections without documentation that McGeer's criteria were met, and multiple antibiotic orders for residents with no documented signs or symptoms. The IP stated the program lacked required components and that the facility had identified the same concerns in its antibiotic stewardship oversight.
Failure to Implement Antibiotic Stewardship Program: The facility failed to maintain an ongoing ASP. The Infection Control Antibiotic Stewardship and MDROs policy had not been revised since 4/17/2025, and the DON stated that when she began in February 2026 there was no IPCP or ASP in place. Review of the IPCP binder showed no documentation of antibiotics ordered or resident infections, viruses, or fungal infections for several months, and no ASP was in place during that period.
Incomplete infection surveillance and antibiotic stewardship monitoring were identified. The facility’s logs did not consistently track residents with infections, infection type and location, causative organisms, or IP follow-up actions, and the IP stated surveillance data was not consistently tracked or analyzed after the prior IP’s termination. Review of antibiotic records showed residents on antibiotics were not routinely monitored for appropriateness, culture and sensitivity results, duration, or efforts to reduce unnecessary antibiotic use, and the DON acknowledged there was no active antibiotic stewardship committee.
A resident admitted with enterococcal infection and sepsis had antibiotic orders that did not match the hospital transfer instructions, which called for IV ampicillin. The MAR instead showed oral amoxicillin and later IV daptomycin, with no cultures available to confirm sensitivity or appropriateness. Lab results showed elevated neutrophils, but there was no documentation that the practitioner acknowledged the abnormal value. Nursing notes also documented cloudy, thick urine and a later urine culture with Citrobacter and Candida tropicalis, while the DON stated cultures and antibiotic stewardship documentation could not be found.
The facility failed to maintain a continuous Antibiotic Stewardship Program that included monitoring antibiotic use, tracking resistance, preventing resistance, and following antibiotic-use protocols. The DON and an LPN/IP stated that the regular IP was out of the country and that documentation for the program was not available for several months. The facility policy stated the program was part of the overall infection prevention and control program.
Failure to monitor antibiotic use and follow UTI criteria: Two residents were started on antibiotics for presumed UTIs even though the IP confirmed they did not meet McGeer Criteria. One resident had an indwelling catheter and was started on Macrobid, while another resident without a catheter was started on Levofloxacin for urinary symptoms. The IP stated risk-benefit analyses were requested but not documented, and the NHA said the QA committee knew about the issue but no improvement plan had been implemented.
A resident with vaginal itching was ordered miconazole cream for two weeks, but the MAR and eMAR showed multiple missed doses, blank entries, and medication-not-available notes. The record did not show physician notification, resident refusal, or reassessment for ongoing symptoms, and the DON confirmed the antifungal was not given as ordered and the course was not adjusted once the medication became available.
Antibiotic stewardship and infection criteria were not followed for 4 residents who received antibiotics for UTIs that did not meet McGeer criteria. The IP could not locate supporting UA, culture, or organism documentation for Macrobid, Cipro, levofloxacin, and Bactrim DS use, and stated there was no urine dipstick policy or McGeer procedure available; the computer program flagged criteria, but the NP decided whether antibiotics were stopped.
Failure to Monitor Antibiotic Use and Document Stop Dates: A resident with dementia, AKI, COPD, and a history of UTI received multiple antibiotic orders and changes, including prophylactic antibiotics with no stop date, while nursing and physician notes did not document UTI monitoring or antibiotic review. The resident denied urinary symptoms, had diarrhea during treatment, and no UA or urine culture was ordered after admission despite the facility’s antibiotic stewardship policy calling for diagnostic testing and antibiotic orders with an indication and stop date.
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