Failure to Follow Antibiotic Stewardship Protocols for Infection Criteria
Summary
The facility failed to accurately monitor and address the use of antibiotics for a resident when the resident's symptoms did not meet the McGeer's criteria or Loeb minimum criteria for a true infection. According to the facility's policy, the Antibiotic Stewardship Program is intended to optimize infection treatment and reduce adverse events by using established criteria to define infections and guide antibiotic use. However, documentation for one resident showed that antibiotics were prescribed despite the resident being afebrile and lacking purulent sputum, which did not meet the required criteria for initiating antibiotic therapy. The Infection Surveillance Monthly Report and Infection Screening Evaluation did not clearly indicate whether the resident's symptoms met the McGeer's or Loeb criteria, and the medical record lacked evidence of fever or increased sputum at the time antibiotics were ordered. Interviews with the Infection Preventionist (IP) and Director of Nursing (DON) confirmed that the resident's symptoms did not meet the criteria for a true infection and that the physician should have been accurately notified of this when the antibiotic was ordered. The IP acknowledged that the facility's process was not followed, as the resident's symptoms were not properly evaluated against the McGeer's criteria before antibiotics were administered. This failure to adhere to the facility's antibiotic stewardship protocols resulted in the use of antibiotics without sufficient clinical justification as outlined in the facility's own policies.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 89 was affected by this deficient practice. On 7/18/2025, DON provided 1:1 education to IP nurses about facility P&P for antibiotic stewardship program, in particular following the McGeer's criteria and Loeb minimum criteria and notifying primary physician of resident's signs and symptoms for appropriate use of antibiotic medication. 2. 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: All residents were potentially affected by this deficient practice. On 8/4/2025, DON and IP nurse reviewed residents in the last 30 days who received antibiotic and making sure McGeer's and Loeb criteria was followed and verified with primary physician and no other issue was noted. On 8/5/2025-8/8/2025, DON in-serviced all Licensed Nurses about facility P&P for Antibiotic Stewardship program and identifying signs and symptoms in line with McGeer's Criteria and Loeb minimum criteria and verifying with primary physician for appropriate usage of antibiotic medication, especially if resident does not meet McGeer's or Loeb criteria. DON emphasize on documenting in resident's medical record if primary physician insisted on continuing the Antibiotic even if resident infection does not meet McGeer's or Loeb Criteria for unnecessary use of Antibiotic. Resident plan of care will also be updated. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON and IP nurse or designee will oversee this process. If a resident developed signs and symptoms of possible infection, RN supervisor or charge nurse will notify primary care physician (PCP) for the COC. If PCP ordered antibiotic, RN supervisor or charge nurse will initiate appropriate use of antibiotic and might suggest to PCP for additional testing, such as labs before initiating antibiotic use. If PCP insisted to start antibiotic, RN supervisor or charge nurse will document in resident medical records and initiate McGeer's criteria or Loeb minimum criteria and reported to IP nurse. IP nurse will re-evaluate Antibiotic use and if McGeer's Criteria or Loeb criteria was not met, IP nurse would verify with primary physician for antibiotic use and suggest antibiotic timeout. IP nurse would update plan of care based on PCP order. IP Nurse will report antibiotic use monthly to infection control committee and any PCP not complaint with McGeer's and Loeb Criteria will be discuss with Medical Director. Medical record will audit all new antibiotic order for compliance to antibiotic stewardship program and report to DON x 3 months. 4. Facility plans to monitor effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The DON will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025.
Penalty
Resources
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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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