The facility failed to maintain a continuous Antibiotic Stewardship Program as required by its policy and CDC core elements, including monitoring antibiotic use, tracking resistance, and following McGeer’s criteria and diagnostic testing protocols before initiating antibiotics. The written policy required complete antibiotic orders with indication and stop dates and tracking of adherence to clinical documentation and culture practices. However, during a review with the DON and a corporate nurse, surveyors found that documentation for the Antibiotic Stewardship Program was missing for several months, and an internal audit had already identified inadequate documentation, indicating the program was not properly implemented and had the potential to affect all residents.
The facility failed to maintain an effective antibiotic stewardship program when the ICP, who was hired for infection control, reported spending most of their time working as a floor nurse due to staffing shortages and could not consistently perform stewardship duties. The ICP described intended practices such as using McGeer's criteria, audits, and an infection screening tool, but review of infection control records showed missing documentation of resident lab results, clinicians' rationale for antibiotic use, and criteria supporting prescribed antibiotics. The ICP stated the program was only compliant for one month when staffing was adequate, and that requests for additional help and training from corporate were denied. When surveyors requested the antibiotic stewardship policy, no additional information was provided.
Antibiotic stewardship was not effectively implemented when McGeer criteria were incorrectly applied for multiple residents receiving antibiotics. Records showed urine cultures and other diagnostic results that did not match the criteria marked on the worksheets, yet antibiotics were still given for UTI or pneumonia. The IP LPN stated she had not been working at the facility frequently, misunderstood culture thresholds, believed a sensitivity result meant antibiotics were needed, and said she was not able to stop antibiotics.
Failure to monitor and analyze antibiotic use: The facility did not operationalize its antibiotic stewardship program for all residents. During review with the IC RN and DON, the line listing did not document whether infection or antibiotic criteria were met, several symptom fields were blank, and the RN could not verify criteria without reviewing each resident EMR. The monthly antibiotic summary and analysis had not been completed, the antibiogram review entry was unexplained, and staff could not explain how the facility monitored for unnecessary antibiotic use or appropriate duration.
A resident was sent to the hospital for vomiting and returned with antibiotic orders for a UTI, after which the facility documented a suspected healthcare-associated UTI and initiated two courses of antibiotics. The McGeer infection surveillance checklist for this resident was not completed, and a spreadsheet later indicated the resident did not meet McGeer criteria, yet antibiotics were continued based on the hospital diagnosis and a physician’s verbal preference, without documentation of that discussion. The Infection Control RN reported not reassessing residents after antibiotics were ordered and was unsure if physicians reassessed the need, despite facility policy requiring monitoring of response to antibiotics and review of outside antibiotic orders for appropriateness.
Failure to monitor antibiotic use and review antibiotic orders led to two residents receiving antibiotics without clear indication. One resident with dementia and chronic kidney disease was given antibiotics for a presumed UTI despite no documented urinary symptoms and no fever on the temperature log, while another resident returned from the ER on cefuroxime for a UTI even though the culture later showed no bacterial growth. The DON and ICP stated the records did not support the antibiotic use as documented.
A facility failed to complete monthly antibiotic stewardship monitoring, including line listings, antifungal stop dates, and tracking of a resident on prophylactic cephalexin. A resident receiving IV vancomycin for osteomyelitis and MRSA had inconsistent scheduling, no documented peak/trough monitoring for over 30 days, and multiple delays and errors in lab collection and processing, with staff and NP interviews confirming the therapeutic levels were not reviewed.
Failure to monitor urine culture results and communicate antibiotic orders for a resident with a hx of UTI. The resident had a UA ordered, the urine specimen was sent to the lab, and the EMR later showed a positive culture for Klebsiella pneumoniae with a physician note to start Ceftin, but the facility EMR did not document monitoring of the result or the need for an ABX until much later. The IP stated there was miscommunication between the facility EMR and a separate hospital EMR where the lab results and antibiotic order were placed.
Failure to maintain the antibiotic stewardship program resulted in a lack of monitoring of residents receiving antibiotics. The facility could not provide line listings or infection maps for several months, and the IC nurse confirmed those months were not completed. The nurse said antibiotic use was being tracked on paper but had not been entered into a line listing, and no infection maps were observed. The nurse also described using nurse notes, McGeer's criteria, and a 3-day monitoring process for suspected UTI, while physician risk-versus-benefit documentation was only generally consistent.
The facility failed to maintain an effective antibiotic stewardship program for two residents by not documenting required infection criteria or the appropriateness of prescribed antibiotics. For one resident with psychiatric diagnoses, cephalexin was ordered for a reported UTI and earlier infection signs, but the McGeer criteria form was blank, the record lacked documentation of the stated symptoms, and there was no evidence of review of hospital labs or culture reports. For another resident with serious mental illness, Augmentin was ordered multiple times for UTI, the infection report and McGeer worksheet lacked documented signs and symptoms, and progress notes described behavioral issues without infection complaints, while the MAR showed interrupted and then completed antibiotic courses. The ICP reported verbally reviewing antibiotics with physicians but acknowledged that these reviews were not documented, and no records of such reviews for these residents were produced.
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