145783
01/02/2024
Sunrise Skilled Nur & Rehab
333 South Wrightsman Street Virden, IL 62690
F 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent the use of an unnecessary antibiotic for 1 of 3 residents (R3) reviewed for unnecessary medication in the sample of 4.
Residents Affected - Few
Findings include: R3 Order Summary Report, print date of 1/2/24, documents that R3 was admitted on [DATE] with the diagnosis of End Stage Renal Disease. R3's Progress Note, dated 12/1/23, documents, Orders received back from (V8, Physician Assistant) from U/A (urinalysis), urine culture for Macrobid (Nitrofurantoin) 100mg (milligram) po bid (by mouth twice a day) x 7 days. Send Urology and Nephrology copy of report. R3's Medication Administration Report, print date of 12/28/23, documents, Macrobid Oral Capsule 100 mg. Give 100 mg by mouth two times a day for UTI (Urinary Tract Infection) Order date of 12/01/23. R3's Urine Culture, Final Report date of 11/29/23, documents, Gram Negative rods less than 10,000 COL (colony)/ ML (milliliter). In V8's handwriting, 1. Macrobid 100 mg BID x 7 d (day). 2. Send culture. 2. copy to nephrology / urology. R3's Urine Culture, Final Reported date of 11/30/23, documents, Providencia rettgeri greater than 100,000 COL/ML. Proteeus mirabilis greater than 100,000 COL/ML Nitrofurantoin R (resistant). On 1/2/24 at 12:10 PM, V7, Infection Preventionist, stated, I called the provider (V8) and questioned him on why R3 got Macrobid when the organism was resistant to Macrobid. He is just as perplexed as we are. I have found some documentation that had not been scanned into the system yet. I found where the Dialysis center did send a fax over to us stating to change the Macrobid because of his End Stage Renal Disease but by this time he (R3) had finished the antibiotic. I usually go back and check that the organism is sensitive to the antibiotic. This one just got past me. On 1/2/24 at 12:33, V2, Director of Nurses, stated, We just found V8's fax response and it looks like V8 ordered the Macrobid before the culture came back. We did send to Nephrologist (Dialysis Center Doctor) but by the time they answered the antibiotic was finished. The Antibiotic Stewardship Policy / Procedure, dated 3/9/23, documents, Antibiotic Time 'time - out At 72 hours after antibiotic initiation or first dose in the facility, each resident will be reassessed for consideration for antibiotic [NAME], duration, selection, and de-escalation potential.
Page 1 of 2
145783
145783
01/02/2024
Sunrise Skilled Nur & Rehab
333 South Wrightsman Street Virden, IL 62690
F 0881
Implement a program that monitors antibiotic use.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an antibiotic was appropriate for the organism of a urinary tract infection for 1 of 3 residents (R3) reviewed for antibiotic stewardship in the sample of 4.
Residents Affected - Few
Findings include: R3 Order Summary Report, print date of 1/2/24, documents that R3 was admitted on [DATE] with the diagnosis of End Stage Renal Disease. R3's Progress Note, dated 12/1/23, documents, Orders received back from (V8, Physician Assistant) from U/A (urinalysis), urine culture for Macrobid (Nitrofurantoin) 100mg (milligram) po bid (by mouth twice a day) x 7 days. Send Urology and Nephrology copy of report. R3's Medication Administration Report, print date of 12/28/23, documents, Macrobid Oral Capsule 100 mg. Give 100 mg by mouth two times a day for UTI (Urinary Tract Infection) Order date of 12/01/23. R3's Urine Culture, Final Report date of 11/29/23, documents, Gram Negative rods less than 10,000 COL (colony)/ ML (milliliter). In V8's handwriting, 1. Macrobid 100 mg BID x 7 d (day). 2. Send culture. 2. copy to nephrology / urology. R3's Urine Culture, Final Reported date of 11/30/23, documents, Providencia rettgeri greater than 100,000 COL/ML. Proteeus mirabilis greater than 100,000 COL/ML Nitrofurantoin R (resistant). On 1/2/24 at 12:10 PM, V7, Infection Preventionist, stated, I called the provider (V8) and questioned him on why R3 got Macrobid when the organism was resistant to Macrobid. He is just as perplexed as we are. I have found some documentation that had not been scanned into the system yet. I found where the Dialysis center did send a fax over to us stating to change the Macrobid because of his End Stage Renal Disease but by this time he (R3) had finished the antibiotic. I usually go back and check that the organism is sensitive to the antibiotic. This one just got past me. On 1/2/24 at 12:33, V2, Director of Nurses, stated, We just found V8's fax response and it looks like V8 ordered the Macrobid before the culture came back. We did send to Nephrologist (Dialysis Center Doctor) but by the time they answered the antibiotic was finished. The Antibiotic Stewardship Policy / Procedure, dated 3/9/23, documents, Antibiotic Time 'time - out At 72 hours after antibiotic initiation or first dose in the facility, each resident will be reassessed for consideration for antibiotic [NAME], duration, selection, and de-escalation potential.
145783
Page 2 of 2
