Failure to Follow Antibiotic Stewardship Protocols for Two Residents
Summary
The facility failed to implement its Antibiotic Stewardship Program policy and procedure for two residents who were prescribed antibiotics without meeting the established criteria. One resident, admitted with type 2 diabetes, a foot ulcer, osteomyelitis, and a right foot amputation, was prescribed intravenous Piperacillin Sod-Tazobactam. Review of the resident's Infection Screening Evaluation indicated that the symptoms did not meet McGeer’s criteria for infection, and the Antibiotic Time Out form did not show that the physician was notified of this. Another resident, admitted with acute kidney failure and a urinary tract infection, was prescribed oral Ciprofloxacin. The Infection Screening Evaluation for this resident also indicated that McGeer’s criteria were not met, and the Antibiotic Time Out was not completed within the required timeframe. Interviews with the infection preventionist nurse revealed a lack of awareness regarding the antibiotic use for one resident and a failure to complete the required Antibiotic Time Out documentation. The infection preventionist nurse confirmed that the physician should be notified when criteria are not met and that this communication should be documented, but this was not done in either case. The facility’s policy states that McGeer criteria are used to define infections and that education on the antibiotic stewardship program should be provided to staff, practitioners, residents, and families, but these procedures were not followed for the two residents involved.
Plan Of Correction
F881 - Antibiotic Stewardship Program How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On 5/29/25, the Infection Prevention Nurse (IPN) reviewed the antibiotic stewardship for Resident 43 and 154 and notified the MD. (Exhibit #30) How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: - On 6/2/25, the IPN reviewed the list of residents on antibiotics, checked if the residents met McGeer's criteria, and if the physician was notified for the antibiotic time out. (Exhibit #31) - No other resident was affected by the same deficient practice. What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 6/2/25, the Director of Nursing (DON) provided one-on-one in-service to the IPN regarding the facility policy and procedure entitled, "Antibiotic Stewardship Program" dated 12/2022. (Exhibit #32) - Starting on 6/17/25, the IPN provided in-service to the active licensed nurses regarding the policy and procedure entitled, "Antibiotic Stewardship Program" dated 12/2022. (Exhibit #33) - Beginning on 6/17/25, the DON will review the Antibiotic Stewardship Program weekly for three months to ensure the physicians were notified if there is an antibiotic time out. (Exhibit #34) - Starting on 6/17/25, the IPN will report to the administrator for any non-compliance. How the facility plans to monitor its performance to make sure that solutions are sustained: - The IPN will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified after. Date of completion: June 20, 2025
Penalty
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The facility failed to complete a comprehensive antibiotic time-out review for two residents receiving doxycycline for sinus infection and cellulitis. Progress notes showed ongoing symptoms and, for one resident, increased confusion with minimal improvement, but the documentation did not show that the prescribing provider was notified or that a decision was made to continue, change, or stop the antibiotic. The DON, IP, and administrator confirmed the facility documented the review in progress notes but did not communicate the assessment to the provider.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use McGeer Criteria Before UTI Antibiotics Were Ordered: The facility did not document that two residents met McGeer Criteria before IV or oral antibiotics were started or continued for presumed UTI. One resident received meropenem and later Levaquin without documented UTI signs or symptoms or justification after culture results, and another resident received Cipro and then Macrobid despite no documentation supporting ongoing UTI symptoms. The DON stated the Macrobid order lacked documentation and did not meet McGeer criteria.
The facility failed to maintain and implement its antibiotic stewardship and infection surveillance program, as required by its own policy. For most months reviewed, there were no infection control records, including antibiotic order listings, documentation confirming infections, surveillance logs, or trend analyses, and the only available data for one month was an unstructured list of residents who received antibiotics without formal tracking of infection rates or antibiotic use. The DON, who was also expected to serve as the Infection Preventionist, reported being unable to locate infection control reports or surveillance data for an extended period, and the Administrator confirmed that, during a time of multiple interim DONs, infection control tracking and analysis of infection and antibiotic use trends had not been completed.
A resident with severe dementia, recurrent UTIs, and bowel and bladder incontinence had a care plan directing staff to monitor for UTI signs and symptoms. Nursing documentation later described manic behavior, loudness, hallucinations, decreased oral intake, and urinary incontinence, after which staff performed a urine dip, notified the provider, obtained an order for a urine culture, and started Keflex. Record review showed no documented urinary symptoms meeting Revised McGeer’s Criteria for UTI without a catheter, despite the facility’s use of these criteria for antibiotic stewardship. The IP confirmed that the resident did not meet McGeer’s Criteria and acknowledged that nursing staff should not have done a urinalysis and did not follow the established criteria, resulting in inappropriate initiation of antibiotic therapy.
The facility lacked an antibiotic stewardship program, with no protocols to ensure appropriate indication, dose, and duration of antibiotic prescriptions and no system to monitor antibiotic use or resistance patterns. When surveyors requested Infection Control Surveillance Logs, including antibiotic tracking information, the logs were not available. In an interview, the DON, who also functioned as the Infection Preventionist, acknowledged that she did not track resident antibiotic utilization, clinical indications, or treatment durations.
Failure to Complete Antibiotic Time-Out Review
Penalty
Summary
The facility failed to complete a comprehensive assessment for continued antibiotic use for 2 of 3 sampled residents reviewed for antibiotic stewardship. Review of the CDC Core Elements of Antibiotic Stewardship for Nursing Homes identified that residents should be evaluated for clinical signs and symptoms when first suspected of having an infection and then comprehensively reviewed within 48-72 hours after starting an antibiotic to determine whether the medication is effective. The facility’s monthly antibiotic surveillance reports from January 2026 through April 2026 included fields for symptoms, diagnostic testing, antibiotic start and end dates, and antibiotic reassessment time out, but the documentation for two residents did not show a complete review of whether treatment was working. For R19, the surveillance report identified nasal congestion and a diagnosis of sinus infection. R19 was started on doxycycline 100 mg orally twice a day for 7 days, and an antibiotic time-out was documented as completed. However, the report did not include information in the date symptoms resolved column to show whether treatment was successful or whether the antibiotic needed to be changed or continued. Progress notes showed that R19 was seen by the facility doctor and started on doxycycline, and later staff documented continued sinus symptoms with thick mucus while also noting that R19 reported feeling better. The note did not identify that the doctor was notified or reviewed the information to make an informed decision about continuing, changing, or discontinuing the antibiotic. For R22, the surveillance report identified redness, warmth, and swelling with a diagnosis of cellulitis. R22 was started on doxycycline 100 mg orally twice a day for 7 days, and an antibiotic time-out was documented as completed. The report did not include information in the date symptoms resolved column to show whether treatment was successful or whether the antibiotic needed to be changed or continued. Progress notes showed that R22 continued to have redness, slight swelling, and warmth to the right lower extremity, and staff noted increased confusion with minimal, if any, improvement from the antibiotic. The note did not identify that the doctor was notified or reviewed the information to make an informed decision about continuing, changing, or discontinuing the antibiotic. The DON, IP, and administrator interviews confirmed that the facility documented the time-out in progress notes, did not communicate the assessment information to the prescribing provider, and relied on whether symptoms improved to determine if the antibiotic was working.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use McGeer Criteria Before Starting or Continuing UTI Antibiotics
Penalty
Summary
The facility failed to promote antibiotic stewardship by using antibiotic therapy for urinary tract infections without documentation that the residents met McGeer Criteria. For two of three residents reviewed, antibiotics were started or continued despite the record lacking documentation of the required signs or symptoms of UTI and, in one case, despite culture results that did not support the treatment decision. The deficiency involved Resident 42 and Resident 5, both of whom had complex medical histories including urinary issues and other chronic conditions. For Resident 42, the record showed a history of recurrent UTI concerns, prior ESBL in the urine, and a cystoscopy with urology follow-up that was not completed. In March 2026, a urinalysis was ordered for agitation, and the NP planned IV antibiotics before final culture results were available. The resident received IV meropenem for a complicated UTI even though the final culture showed 10-50,000 colonies of Proteus mirabilis not ESBL, and there was no documentation explaining why the IV antibiotic was continued after the final culture. The record did not document physical signs or symptoms of UTI. In late April 2026, another urinalysis was obtained after the resident reported bladder soreness, painful urination, and frequency, and the final culture showed Morganella morganii 10-50,000 colonies. Levaquin was ordered, but there was no documentation from the NP explaining why the antibiotic was ordered or documenting continued UTI signs or symptoms. For Resident 5, the record showed diagnoses including acute cystitis, bacteremia, kidney and bladder disorders, urinary retention, UTI, and ESBL. The resident was moderately impaired for daily decision making and always incontinent of bladder. In April 2026, a family request prompted a urinalysis to rule out infection, and the UA showed blood, nitrates, many bacteria, and leukocytes. Cipro was ordered before the final culture, but the culture later showed ESBL E. coli resistant to Cipro, and the antibiotic was discontinued. Shortly afterward, Macrobid was ordered for UTI/ESBL, yet there was no documentation from the NP explaining why it was ordered or documenting ongoing UTI signs or symptoms such as burning, pain, or frequency. The DON stated there was no documentation of why Macrobid was started when it did not meet McGeer criteria, and the record did not show that the resident had signs or symptoms of UTI.
Failure to Maintain Facility-Wide Antibiotic Stewardship and Infection Surveillance
Penalty
Summary
The facility failed to implement a facility-wide system to monitor antibiotic use as required by its Antibiotic Stewardship Program policy. The policy, last revised in December 2016, required that all clinical infections treated with antibiotics undergo review by the Infection Preventionist or designee, including review of antibiotic utilization, antibiotic orders, clinical documentation confirming infections, infection surveillance logs, microbiology testing, and trends in infection and antibiotic use data. Surveyors found that for eight of nine months reviewed—July, August, September, October, November, and December 2025, and February and March 2026—the facility was unable to provide any infection control data, including listings of antibiotic orders, clinical documentation confirming infections, surveillance logs, or trending of infections. For January 2026, the facility had only a list of residents who exhibited symptoms and were treated with antibiotics, but did not use a structured tool to track infection rates, antibiotic use, or to monitor, conduct surveillance, or identify trends related to infections or possible infections. During interviews, the DON, who assumed the position on April 13, 2026 and was also expected to function as the Infection Preventionist, reported being unable to locate Infection Control reports, surveillance records, or infection tracking data for July 2025 through April 2026, except for the January list of residents who received antibiotics. The Administrator confirmed that multiple interim DONs had served since July 2025 and acknowledged that tracking of infection control data, including infection trends and antibiotic use, had not been completed, despite the facility’s stated intent for a comprehensive Infection Control Program that included surveillance, tracking, and trend analysis.
Failure to Follow McGeer’s Criteria for Antibiotic Use in Suspected UTI
Penalty
Summary
The facility failed to implement antibiotic stewardship and ensure appropriate clinical indications for antibiotic use for a resident evaluated for a suspected urinary tract infection (UTI). The resident had multiple diagnoses including severe dementia, recurrent UTIs, and insomnia, and a care plan dated 12/9/19 documented bowel and bladder incontinence related to impaired cognition, with directions for staff to monitor for signs and symptoms of UTI. On 3/16/26 at 6:14 PM, a nursing progress note documented that the resident was exhibiting manic behavior, was loud, hallucinating, and had decreased oral intake. The note also documented urinary incontinence, that a urine dip was performed, the provider was notified, an order was obtained for a urine culture, and Keflex was started. Record review showed there was no documentation of worsening urinary symptoms that met the Revised McGeer’s Criteria for UTI without an indwelling catheter, which the facility had adopted for antibiotic stewardship. The Infection Preventionist (IP) confirmed on 4/30/26 at 3:48 PM that the facility followed McGeer’s Criteria for antibiotic stewardship and presented a quarterly antibiotic tracking report indicating the resident did not meet McGeer’s Criteria. When asked, the IP stated that nursing staff should not have done a urinalysis on this resident and acknowledged that the nurses did not follow McGeer’s Criteria. This sequence of actions and lack of required clinical indications led to the determination that the facility failed to ensure appropriate antibiotic use.
Failure to Implement and Monitor an Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. There was no established facility-wide system to ensure appropriate indication, dose, and duration for antibiotic prescriptions, and no process for monitoring antibiotic usage or resistance data. On 4/29/26 at 8:20 AM, when surveyors requested the facility’s Infection Control Surveillance Logs, including any prescribed antibiotic tracking information, these logs were unavailable. On 4/30/26 at 12:28 PM, during an interview, the DON, who also served as the facility’s designated Infection Preventionist, stated that she did not track resident antibiotic utilization, including the specific clinical indications for the medications or the prescribed durations of treatment. No specific residents, their medical histories, or clinical conditions at the time of the deficiency were described in the report.
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