Incomplete Antibiotic Stewardship Monitoring: The facility failed to maintain consistent antibiotic stewardship and infection surveillance tracking. Review showed missing monitoring records for several months, while four residents were receiving antibiotics for UTI and URI. The Infection Control Nurse, DON, and Administrator stated the binder should have been kept up to date, but the Infection Control Nurse reported she had been working frequently as a charge nurse and had not completed the required tracking.
Failure to implement an ASP and monitor antibiotic use: the facility did not maintain a complete infection/antibiotic control log for several months, and the logs that were reviewed showed repeated missing documentation for signs and symptoms, site of infection, onset of symptoms, culture status, pathogen identification, and whether the infection resolved. The IP said he/she gathered antibiotic-use information but did not know what information was required, while the DON, ADON, and administrator identified the IP as responsible for tracking and trending antibiotic use and infections.
Failure to Maintain Antibiotic Stewardship Monitoring and Tracking: The facility did not implement its ASP as written, and the IP/DON did not maintain a process to track and trend antibiotic use. Infection/antibiotic control logs were missing for multiple months, and the logs that were completed showed repeated gaps in documentation for signs and symptoms, infection site, onset, culture status, pathogen identification, and infection resolution. The DON stated the logs were not being filled out consistently and that no trending was being done, while the administrator was unaware the monitoring was not occurring.
Failure to Track and Trend Antibiotic Use: Facility staff did not implement an ASP with antibiotic use protocols or a system to monitor and trend antibiotic use. The IP said he/she was responsible for the program but had only recently started in the role and had not completed tracking and trending for the current month, while the DON and administrator acknowledged that antibiotics and infections were not being tracked on paper or through graphs daily or weekly, despite the facility policy calling for tracking, reporting, and performance evaluation of antibiotic use and infection data.
The facility did not maintain an active antibiotic stewardship program as required by its own policy. The written policy, dated 7/1/25, called for an antibiotic stewardship program integrated with infection prevention and control, led by the Medical Director, DON, IPC nurse, and consultant pharmacist, with support from the Administrator and governing officials, and intended to optimize infection treatment and reduce adverse events from antibiotic use. However, the Administrator reported that the program had not been updated for many months, the IPC nurse had recently left, and the program had only just been restarted, leaving the facility without established antibiotic use protocols or a system to monitor antibiotic use for its resident population.
Failure to Track and Trend Antibiotic Use: Facility staff did not implement an Antibiotic Stewardship Program with protocols to monitor and track antibiotic use. The ADON said he/she tried to review residents on antibiotics using EMR order reports and McGeers assessments, but had no printed reports, no documentation of physician contact, and no tracking or trending data for the past year. The DON said the ADON was responsible for the program, while the Administrator said the ADON should be maintaining the documentation and knowing the top infection trends.
A resident was prescribed and administered antibiotics for a UTI without timely completion of an infection screening evaluation by the Infection Preventionist, as required by the facility's antibiotic stewardship policy. The IP was not informed of the resident's UTI status upon return from the ER and did not review the orders, resulting in a delay in completing the infection worksheet and evaluating the appropriateness of the prescribed antibiotic.
The facility did not have a functioning antibiotic stewardship program or a designated Infection Preventionist (IP), as required by its own policies. The only full-time RN, who previously served as IP, was unable to continue due to workload, and there was no tracking of infections or antibiotic use. Interviews with corporate and administrative staff confirmed the lack of oversight and documentation for infection control and antibiotic monitoring.
Facility staff did not notify the physician of a resident's urine culture and sensitivity results, which showed E. coli resistant to the prescribed antibiotic Bactrim DS. The resident, with multiple chronic conditions, was treated for cellulitis, but the required communication of lab results to the physician did not occur, as the Infection Preventionist failed to follow protocol.
A facility failed to maintain an effective IPCP, including an antibiotic stewardship program, by not documenting appropriate indications for antibiotic use for a resident. The resident was prescribed doxycycline for a wound infection and Flagyl for diarrhea without necessary lab reports or findings. The DON confirmed the lack of a stool culture for Flagyl, and the Administrator acknowledged the failure to follow standard procedures.
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