HospitalInspections.org

Based on interview and record review, the facility failed to ensure there was a qualified individual who was appointed by the Governing body to be over the antibiotic stewardship. This was found in 1 of 1 physicians who was identified as being over the program (Physician #7).

This deficient practice had the likelihood to cause harm to all patients.

Findings include:



During an interview on 01/13/2022 after 10:22 a.m., Staff #50 (Interim Director of Pharmacy) said she had been in her position since 11/01/2021. Staff #50 said that the facility had only 2 of 4 pharmacy and therapeutic (P&T) meetings for 2021. Staff #50 said that Physician #7 was over the antibiotic stewardship program, but when staff had a question they called Physician #15.

Review of "NOMINATING COMMITTEE "minutes dated 09/20/2019 revealed Physician #7 was over the Pharmacy and Therapeutic committee. There was no mention of Physician #7 being over the antibiotic stewardship program.

Review of Physician #7's credentialing file dated 09/2021 revealed no documented training or education in infectious disease or antibiotic stewardship.

During an interview on 01/14/2022 after 8:10 a.m., Registered nurse #40 (Chief quality officer) confirmed the information in the credentialing file and committee minutes. Registered nurse #40 said she had already talked to Physician #7 and told him that they needed to get training on his file.