FEDERAL WAY, WA - State inspectors cited Avalon Care Center - Federal Way for widespread failures in its antibiotic stewardship program, finding the facility failed to properly monitor antibiotic use for all six residents reviewed during a July 2024 inspection.
Systematic Breakdown in Antibiotic Oversight
The July 24, 2024 inspection revealed that Avalon Care Center had failed to implement an effective Antibiotic Stewardship Program (ASP), a critical safety measure designed to ensure residents receive the right antibiotics at the right dose for the right duration. Inspectors found that none of the six residents reviewed had proper documentation supporting their antibiotic treatments.
The facility's own policies required validation that antibiotics were prescribed for the correct indication, dose, route, and duration. However, inspectors discovered that staff had not completed the required McGeer's criteria assessments - a standardized tool that uses specific signs and symptoms to verify active infection - for any of the residents on antibiotic therapy.
According to facility policy, an Antibiotic Time-Out Checklist should be completed within 48-72 hours after starting any antibiotic treatment and reviewed with the prescribing physician. This critical safety check was missing for multiple residents, leaving no documented evidence that their antibiotic treatments were medically necessary or appropriate.
Critical Documentation Failures
The inspection revealed particularly concerning gaps in the facility's antibiotic tracking system. The required line listing - a comprehensive log of all residents receiving antibiotics - was both incomplete and inaccurate. Staff could not provide complete antibiotic documentation from the previous survey period to the current inspection date.
Two residents, identified as Resident 204, had received multiple antibiotics that were never documented on the facility's antibiotic stewardship line listing. This fundamental tracking failure meant facility staff had no systematic way to monitor these treatments or assess their appropriateness.
Residents 80 and 77 both completed full courses of antibiotic treatment without any documented symptoms that would meet the McGeer's criteria for antibiotic use. This represents a significant breakdown in clinical oversight, as antibiotics should only be prescribed when there is clear evidence of bacterial infection.
The case of Resident 64 highlighted potentially dangerous prescribing practices. This resident was admitted on antibiotics for colitis, but hospital records showed the colitis had already resolved. The antibiotic was then continued for pneumonia treatment, despite hospital chest X-rays showing no evidence of pneumonia. This represents both inappropriate continuation of unnecessary antibiotics and failure to verify the medical indication for treatment.
Medical Significance of Antibiotic Stewardship
Proper antibiotic stewardship is essential for resident safety and public health. When antibiotics are used inappropriately or unnecessarily, residents face increased risks of adverse drug reactions, antibiotic-associated infections like C. difficile colitis, and development of antibiotic-resistant bacteria.
The McGeer's criteria serve as an evidence-based foundation for antibiotic prescribing in long-term care facilities. These criteria require specific combinations of symptoms - such as fever, elevated white blood cell count, or positive cultures - before antibiotics are considered appropriate. Without this systematic assessment, residents may receive unnecessary treatments that expose them to risks without medical benefit.
Antibiotic resistance represents one of the most serious threats to modern healthcare. When facilities fail to monitor antibiotic use appropriately, they contribute to the development of "superbugs" - bacteria that no longer respond to standard treatments. This puts not only individual residents at risk but also threatens the broader community's ability to treat bacterial infections effectively.
The 48-72 hour antibiotic timeout represents a crucial intervention point where healthcare providers should reassess whether continued antibiotic therapy is necessary. During this review, providers should evaluate culture results, clinical response, and whether the initial indication for treatment was correct. This systematic approach helps prevent unnecessarily prolonged antibiotic courses.
Staffing Challenges and Resource Allocation
The facility's Infection Preventionist revealed significant staffing challenges that contributed to the program failures. During the inspection interview, Staff C acknowledged that maintaining three separate roles - Assistant Director of Nursing, Staff Development Coordinator, and Infection Preventionist - made it difficult to adequately fulfill infection prevention responsibilities.
This staff member stated: "it was important to complete a McGeer's & Loeb's assessment to ensure the resident was receiving the correct ABO and to ensure the ABO was necessary." Despite recognizing this importance, the facility had not completed these critical assessments for any residents.
The infection preventionist also revealed that while the facility had software designed to track whether residents met McGeer's or Loeb's criteria, the system failed to document the specific clinical data that would justify antibiotic use. This technological gap meant that even when staff indicated a resident met criteria for treatment, there was no supporting evidence to verify the appropriateness of that decision.
Industry Standards and Best Practices
Federal regulations require nursing homes to maintain comprehensive infection prevention and control programs that include antibiotic stewardship as a core component. The Centers for Disease Control and Prevention has established clear guidelines for implementing these programs in long-term care settings.
Effective antibiotic stewardship programs should include regular review of all antibiotic prescriptions, tracking of antibiotic use patterns, education for prescribing providers, and systematic assessment using validated criteria like McGeer's definitions. These programs should also include regular meetings to review antibiotic use data and identify opportunities for improvement.
The facility's policy required maintaining documentation including meeting minutes, tracking information, and logs in a dedicated binder to facilitate reviews and comparisons over time. This type of systematic record-keeping allows facilities to identify trends, monitor the effectiveness of interventions, and demonstrate compliance with regulatory requirements.
Additional Issues Identified
Beyond the major documentation failures, the inspection revealed several other concerning aspects of the facility's antibiotic management:
The facility's antibiotic stewardship binder, which should contain meeting minutes and tracking logs, was not being maintained as required by policy. This represents a fundamental breakdown in the program's infrastructure and oversight mechanisms.
Staff had not completed required antibiotic assessments for residents who had recently completed antibiotic courses, missing opportunities to evaluate treatment outcomes and learn from recent prescribing decisions.
The facility's tracking system failed to capture all residents receiving antibiotics during July 2024, creating gaps in oversight that could allow inappropriate prescribing to continue undetected.
The inspection findings suggest systemic issues with clinical oversight and quality assurance processes that extend beyond just antibiotic management, raising questions about the facility's overall approach to evidence-based medical care and resident safety monitoring.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avalon Care Center - Federal Way from 2024-07-24 including all violations, facility responses, and corrective action plans.
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