Health inspection·January 7, 2025

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility ' s nursing staff failed to update and maintain the facilities Antibiotic Steward Program. (Log used to identify, track, and monitor infections and antibiotic use for the residents.) Residents Affected - Some This failure had the potential to result in an inadequate antibiotic stewardship program to identify potential inappropriate antibiotic use and antibiotic resistance. Findings: A review of Resident 2 ' s medical records indicated a urinalysis (UA-test for bacteria in the urine) was ordered on 12/5/24. Laboratory results indicated a culture and sensitivity (C&S- test to determine the type of bacteria and what antibiotic would treat the infection) which showed positive Escherichia coli. (E.coli-bacteria). A review of Resident 3 ' s medical records indicated a UA was ordered on 12/9/24. Laboratory results indicated C&S positive for E.coli. A review of Resident 4 ' s medical records indicated a UA was ordered on 12/10/24. Laboratory results indicated C&S positive for E.coli. A review of Resident 5 ' s medical records indicated a UA was ordered on 12/19/24. Laboratory results indicated C&S positive for Citrobacter freundii.(bacteria) A review of Resident 6 ' s medical records indicated a UA was ordered on 12/20/24. Laboratory results indicated C&S positive for polymicrobic growth (multiple types of microorganism), probable skin contamination per lab. A review of Resident 7 ' s medical records indicated a UA was ordered on 12/22/24. Laboratory results indicated C&S positive for E.coli. A review of Resident 8 ' s medical records indicated a UA was ordered on 12/25/24. Laboratory results indicated C&S indicated minimal growth. A review of Resident 10 ' s ' medical records indicated a UA was ordered on 12/28/24. Laboratory results indicated C&S positive for Staphylococcus aureus (bacteria). A review of the facility ' s record, [Facility Name] Antibiotic Steward Program (ASP), dated December 2024, indicated 15 residents were monitored for antibiotic use. The record indicated that each Page 1 of 3 555433 555433 01/07/2025 Eastern Plumas Hospital- Portola Campus Dp/Snf 500 First Street Portola, CA 96122

F 0881 resident was to have 10 criteria monitored. The record indicated the following criteria were missing or incomplete: Level of Harm - Minimal harm or potential for actual harm Date: 3 out of 15 missing. (Residents 1,2,3) Residents Affected - Some Residents Medical Record number: 1 out of 15 missing. (Resident 3) Dose and Duration: 2 out 15 missing (Resident 1,8) and 1 out of 15 was incomplete (Resident 3). Start and Stop Date: 3 out of 15 missing (Residents 1,2,3) and 4 out 15 was incomplete. (Residents 1,3,4,10) Clinical Indications Document signs and symptoms, date of culture: 7 out of 8 were missing date of culture. (Residents 2,4,5,6,7,8,10). Diagnosis: 1 out of 15 was missing. (Resident 2) Date and initial of nurses that faxed to outside pharmacy: 2 out of 15 were missing (Residents 1,8) and 4 out of 15 were incomplete (Residents 3, 4, 5, 10). Date that culture and sensitivity results faxed and to pharmacist: 7 out of 8 were missing. (Residents 2,4, 5,6,7,8,10). During an interview on 1/7/25 at 2 pm with Infection Preventionist (IP), IP stated, the ASP was the log used to track and investigate infections and antibiotic use for the residents. IP confirmed information on the ASP was missing and incomplete. IP confirmed that all the information needed to be complete and updated on the ASP log to analyze, monitor, and minimize the emergence and spread of antimicrobial resistance (bacteria that becomes resistant to antibiotics due to overuse or use of the wrong antibiotic) and to ensure safe and appropriate use of antimicrobial agents. During an interview on 1/7/25 at 2:10 pm with Director of Nursing (DON), DON confirmed all the boxes should be filled out and be updated by the nurses. DON confirmed information on the ASP was missing and incomplete. DON confirmed that all the information needed to be complete and updated on the ASP log to analyze, monitor, and minimize the emergence and spread of antimicrobial resistance and to ensure safe and appropriate use of antimicrobial agents. A review of facility Policy and Procedure (P&P) titled Infection Prevention and Control Plan (IPCP), dated 11/2024, indicated: A. The facility shall develop and implement an IPCP with a goal of reducing risk of acquiring and transmitting Healthcare-Associated Infections (HAIs) and to investigate and manage communicable (spread from person to person) disease outbreaks. B. Systems to provide access to information will be provided to support infection prevention and control (IPC) activities. C. Department managers and/or designees are responsible for monitoring employees and assuring compliance with IPC P&Ps. Healthcare workers will adhere to the infection prevention policies. 555433 Page 2 of 3 555433 01/07/2025 Eastern Plumas Hospital- Portola Campus Dp/Snf 500 First Street Portola, CA 96122

F 0881 Level of Harm - Minimal harm or potential for actual harm D. IPC management functions are delegated to the Infection Preventionist (IP)/Infection Control Committee (ICC) to investigate and follow up on clinical issues. Duties include: 1. Reviewing surveillance data monitoring for trends in infections, clusters, infections due to unusual pathogens (an organism that can produce disease), or any occurrences of HAIs. Residents Affected - Some 2. Reviews trends in antibiotic susceptibility/resistance (if the pathogen will be killed by an antibiotic or resist it). E. Prevention and/or risk reduction includes identifying and preventing HAIs by monitoring the appropriate use of antibiotics and other antimicrobials (something that kills growth of bacteria, mold, fungi, and viruses). F. Managing Critical Data and Information: Surveillance data will be analyzed appropriately and used to monitor and improve infection control and healthcare outcomes. A review of facility P&P titled Antimicrobial Stewardship Program (ASP), dated 9/2024, indicated: A. The Antimicrobial Stewardship Committee has been formed to evaluate, report, and monitor the use of antimicrobial agents. Members include a Medical Director, Clinical Pharmacist, Microbiologist, representatives from Quality/Performance Improvement and other vested practitioners, including the Chief Nursing Officer. B. The facility maintains an ASP to minimize the emergence and spread of antimicrobial resistance and to ensure safe and appropriate use of antimicrobial agents. C. The ASP interventions will include conducting retrospective (looking back) and prospective (looking forward) antimicrobial use evaluations and review/track trends in microbial resistance/susceptibility. 555433 Page 3 of 3