Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an active antibiotic stewardship program and did not perform antibiotic time-outs for three of five residents reviewed for antibiotic use. For one resident with severely impaired cognition and a diagnosis of Alzheimer's dementia, an order for azithromycin was initiated for an upper respiratory infection, but no antibiotic time-out was documented. Another resident with moderately impaired cognition and multiple diagnoses, including UTI and heart failure, received Macrobid for a suspected UTI, despite negative culture results and absence of UTI symptoms, without an antibiotic time-out recorded. A third resident with intact cognition and a history of UTI, heart disease, and diabetes was prescribed Levaquin for a UTI, but the medical record lacked documentation of an antibiotic time-out for this course of therapy. Interviews with nursing staff revealed inconsistent knowledge and application of infection criteria, such as McGeer's, and a lack of awareness regarding the facility's chosen criteria for infection assessment. The facility's infection control software relied on user input to trigger antibiotic time-outs, but this process was not consistently followed. The facility's policy required antibiotic reviews (time-outs) 48-72 hours after initiation, but these were not found in the records of the affected residents. Staff interviews confirmed the absence of required antibiotic time-outs and inconsistent posting and understanding of infection assessment criteria.