SPOKANE, WA - A July 2024 inspection at Spokane Health & Rehabilitation revealed systemic failures in antibiotic management that placed residents at risk of developing drug-resistant infections, according to state health surveyors. The facility was cited for failing to properly implement protocols ensuring antibiotics were appropriately prescribed for at least two residents who received multiple courses of treatment for urinary tract infections.
Recurrent Infections Without Proper Testing
One resident, identified in the report as Resident 9, received six separate courses of antibiotics for urinary tract infections between January and May 2024. The resident was treated with antibiotics on January 2-9, January 22-27, February 8-19, February 13-21, April 29-May 6, and May 21-28. However, documentation revealed that urine cultures were not consistently obtained before starting treatment, and when they were ordered, results sometimes showed bacterial counts below the threshold typically requiring antibiotic therapy.
Medical protocols require specific criteria to be met before diagnosing a urinary tract infection and initiating antibiotic treatment. According to the McGeer Criteria—industry-standard guidelines for diagnosing infections in long-term care settings—residents without urinary catheters must exhibit clear symptoms such as painful urination or fever, combined with laboratory confirmation showing bacterial counts exceeding 100,000 colony-forming units.
In this case, one urine sample collected on May 15, 2024, showed a bacterial count below this threshold, yet the resident continued to receive antibiotic treatment. Additionally, urine culture results for samples ordered on February 7 and April 28 were never documented in the medical record, raising questions about whether treatment decisions were made without proper laboratory confirmation.
The resident told surveyors they experienced "little twinges" and would request urine cultures because they "wanted to know if they had a UTI or just a twinge." The resident also acknowledged using an "unsanitary perineal technique" for personal hygiene due to mobility limitations, which could have contributed to recurrent infections.
Medical Significance of Antibiotic Stewardship
Inappropriate antibiotic use poses serious health risks beyond treating the immediate infection. When antibiotics are prescribed without proper diagnostic confirmation or when they are used too frequently, bacteria can develop resistance to these medications. This means that when a resident genuinely needs antibiotics for a serious infection, the drugs may no longer be effective.
The Centers for Disease Control and Prevention emphasizes that antibiotic stewardship—the systematic effort to measure and improve how antibiotics are prescribed—is critical for protecting patients from unnecessary side effects while combating antibiotic resistance. Side effects from antibiotics can range from relatively minor issues like nausea and dizziness to more serious complications including severe diarrhea and secondary yeast infections.
For nursing home residents, who often have compromised immune systems and multiple chronic health conditions, developing antibiotic-resistant infections can be life-threatening. These infections are harder to treat, may require hospitalization, and can spread to other vulnerable residents.
Second Resident Experienced Similar Pattern
A second resident, Resident 10, received four separate antibiotic courses between February and June 2024 for suspected urinary tract infections. Medical records showed this resident was taking Oxybutynin, a medication for overactive bladder, three times daily and experienced frequent urinary incontinence.
Provider notes from March 25, 2024, indicated that antibiotics were started while urine culture results were "still pending," with plans to modify treatment if needed once results became available. On April 28, the resident was evaluated for painful and frequent urination, but records do not clearly document whether culture results confirmed infection before treatment began.
By July 2024, provider notes acknowledged that the resident had "experienced chronic UTI symptoms over their lifetime with frequent treatments" and remained at high risk for infections despite discussions about hygiene practices.
Facility Lacked Consistent Monitoring Systems
When surveyors interviewed nursing staff and the facility's infection preventionist, inconsistencies emerged regarding antibiotic monitoring protocols. One licensed practical nurse stated they were "unsure what tool, protocol or criteria the facility used to determine if antibiotics were needed or appropriately prescribed" and did not know how to monitor antibiotic effectiveness.
The infection preventionist confirmed the facility used McGeer Criteria and tracked antibiotic prescriptions on a surveillance flowsheet. However, the preventionist was unaware of the first resident's hygiene challenges and acknowledged that resident "should have had urinalysis with culture completed prior to being treated with antibiotics to prevent resistant microorganism development."
According to the facility's own infection control policy, culture reports, sensitivity data, and antibiotic usage should be evaluated as part of antibiotic stewardship efforts. The policy stated that the infection preventionist would analyze antibiotic usage data and trends, consult on infection prevention strategies, and implement evidence-based practices. However, facility administrators confirmed that while infections were tracked and trended, no concerning patterns had been identified despite the documented recurrent treatments.
Additional Issues Identified
Beyond the antibiotic management concerns, surveyors noted that neither resident had been offered a formal toileting program despite frequent urinary incontinence. Standard practice in long-term care includes implementing scheduled toileting programs to help reduce incontinence episodes and potentially decrease infection risk. The first resident was described as independent with toileting hygiene but acknowledged mobility limitations that affected their ability to perform adequate personal care—a factor that could have been addressed through staff assistance or adaptive equipment.
Industry Standards and Best Practices
Long-term care facilities are expected to maintain comprehensive infection prevention and control programs that include antibiotic stewardship as a core component. This involves not only tracking when antibiotics are prescribed but actively reviewing whether prescriptions meet clinical criteria, whether diagnostic testing supports treatment decisions, and whether alternative interventions might prevent recurrent infections.
For residents with frequent urinary tract infections, best practices include investigating underlying causes, implementing preventive strategies such as increased fluid intake and improved hygiene assistance, and considering whether medications like Oxybutynin might be contributing to urinary retention that increases infection risk.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Manor Care Health Services-spo from 2024-07-25 including all violations, facility responses, and corrective action plans.
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