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.
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.
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.
The facility did not have an effective system to monitor antibiotic use, as several residents were prescribed antibiotics without proper documentation of clinical indications, review of appropriateness, or consultation with a physician. Infection control logs and medical records lacked evidence of symptom documentation, urinalysis, or culture results, and staff interviews confirmed that antibiotic appropriateness was not consistently reviewed.
The facility did not follow its antibiotic stewardship policy, as multiple residents received antibiotics without consistent use of McGeer's Criteria or other accredited standards. The DON, acting as Infection Control Preventionist, acknowledged that antibiotics were sometimes prescribed based on clinical judgment rather than established protocols, and lacked the required training certificate. Documentation showed that antibiotic use was not accurately tracked or reviewed as required by facility policy.
A resident with a urinary tract infection and a supra-pubic catheter received a prescribed course of Macrobid, but their antibiotic use was not recorded on the facility's antibiotic surveillance log. This omission led to inaccurate infection rate calculations for several months, despite facility policy requiring all infections to be tracked and an antibiotic stewardship program to be in place.
A facility failed to implement an effective antibiotic stewardship program, lacking written protocols, proper documentation, and a monitoring system. A resident with a urinary catheter developed a UTI, and antibiotics were started without documented justification, physician notification, or consideration of lab results and renal function. The medical provider did not document in the EMR, and no care plan for the UTI or antibiotic therapy was present.
The facility did not properly implement or document its Antibiotic Stewardship Program, as shown by incomplete infection surveillance records, missing laboratory data, and lack of documentation for antibiotic use in four residents. Several residents received antibiotics without clear evidence of infection, appropriate assessments, or monitoring, and staff were unable to explain or justify antibiotic choices due to missing or incomplete records.
The facility did not consistently follow established protocols for antibiotic use, as antibiotics were prescribed for UTIs without documented signs or symptoms and without lab confirmation. The Infection Control Preventionist confirmed that antibiotics were sometimes ordered based only on urinalysis, without culture and sensitivity testing, and could not explain how appropriate antibiotic selection was ensured in these cases.
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