Health inspection·April 17, 2024

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 failed to establish an infection prevention and control program that must include, at minimum, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 facility reviewed for an antibiotic stewardship program. Residents Affected - Many The facility did not have pharmacist review for antibiotic stewardship. The facility did not have protocols incorporated in the overall infection prevention and control program and had no system of reports related to monitoring antibiotic usage and resistance data such as the rate of new antibiotic starts, types prescribed or days of antibiotic treatment per 1,000 resident days; antibiotic resistance based on laboratory data from, for example the last 18 months; or tracking measures of outcome surveillance related to antibiotic use. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings include: Record review of Facility Infection Control Log for January 2024 through March 2024 revealed facility maps with color coded rooms and the legend revealed the color to coordinate with the type of infection. There was no tracking form that included if a resident had a lab completed before starting an antibiotic, if they met/did not meet the surveillance criteria in the electronic health record for antibiotic therapy, or if the infections were facility or community acquired. There were no reports that combined all the antibiotic usage. In an interview on 04/17/2024 at 5:20 pm the DON reported she was the infection preventionist. She said the facility was able to monitor the antibiotic use in the facility through the electronic health record. She said the system tracked the number of antibiotics prescribed, the prescriber, the length of time the prescription was utilized, and the diagnosis leading to the prescription for each individual resident. She stated if a resident exhibited symptoms of an infection the nurse completed an assessment for a change of condition and notified the doctor. If an antibiotic was ordered the information was entered on the infection surveillance form in the electronic health record for each individual resident. Information could be located by researching each individual electronic health record, but the facility did not have a list of residents that were on antibiotics. The team, which consisted of the DON, ADON, SW, admission Nurse, and Therapy evaluated the antibiotic usage daily. She reported they informed the doctor of their evaluation, and the doctor accessed the electronic health record for labs. She stated the facility's antibiotic stewardship documentation was contained in the electronic health record. The facility did not have a licensed pharmacist to assess, monitor and Page 1 of 3 675748 675748 04/17/2024 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many communicate antibiotic use. The DON stated she was unaware that a pharmacist was required to monitor antibiotics. In an interview on 04/17/2024 at 5:40 pm with Administrator he reported the facility tracked infections and antibiotics through the Infection Surveillance form in the electronic health record for each resident. He reported the team discussed the antibiotic therapy in the morning meetings to determine the appropriateness of the antibiotics prescribed and inform the doctor of their findings. He reported the Infection Preventionist, who was the DON, was responsible for maintaining infection control. Review of Infection Control Policy dated Qtr. 3, 2018, reflected in part: 3. Surveillance a. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infections, and detecting unusual pathogens with infection control implications. 4. Antibiotic Stewardship a. Culture reports, sensitivity data and antibiotic usage reviews are included in surveillance activities. 5. Data Analysis a. Data gathered during surveillance is used to oversee infections and spot trends. b. One method of data analysis is by manually calculating number of infections per 1,000 resident days as follows: 1. The infection preventionist collects data from the nursing units, categorizes each infection by body site (these can also be categorized by organism or according to whether they are facility or community-acquired), and records the absolute number of infections. 2. To adjust for differences in bed capacity or occupancy on each unit, and to provide a uniform basis for comparison, infection rates can be calculated as the number of infections per 1,000 patient days (a patient day refers to one patient in one bed for one day), both for each unit and for the entire facility. 3. Monthly rates can then be plotted graphically or otherwise compared side-by-side to allow for trend comparison; and 4. Finally calculating means and standard deviations (using computer software) allows for screening of potentially clinically significant rates of infections (greater than two standard deviations above the mean). c. The Medical director will help design data collection instruments, such as infection reports and 675748 Page 2 of 3 675748 04/17/2024 Heritage Trails Nursing and Rehabilitation Center 301 Lincoln Park Dr Cleburne, TX 76033

F 0881 antibiotic usage surveillance forms, used by the Infection Preventionist. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 675748 Page 3 of 3