NEWHALL, CA - Federal inspectors found Santa Clarita Post-acute Care Center failed to properly monitor a resident's long-term antibiotic use, potentially exposing the patient to unnecessary medication risks and antibiotic resistance.
Prolonged Antibiotic Use Without Proper Oversight
During a February 2025 inspection, surveyors discovered that a 37-year-old resident with cognitive impairment had been prescribed methenamine hippurate, an antibacterial medication, for urinary tract infection prevention since September 2023 without adequate monitoring protocols in place.
The resident, who was admitted in March 2023 with multiple medical conditions including thrombocytopenia (low platelet count), gastroesophageal reflux disease, and a history of stroke, had moderate cognitive impairment that affected their ability to make medical decisions. Despite being on this high-risk medication class for over a year, facility staff failed to implement proper monitoring procedures.
According to medical records reviewed during the inspection, the resident was prescribed methenamine hippurate 1 gram tablets twice daily for UTI prevention. However, the medication order contained no provisions for monitoring signs and symptoms of UTI, leaving staff without clear guidance on how to assess the drug's effectiveness or identify potential complications.
Medical Significance of Monitoring Requirements
Methenamine hippurate requires careful oversight due to its potential for adverse effects and the risk of developing antibiotic resistance. The medication works by releasing formaldehyde in acidic urine, which helps prevent bacterial growth in the urinary tract. However, prolonged use without proper monitoring can lead to several serious complications.
According to established medical protocols, patients taking methenamine hippurate should receive regular kidney function monitoring - at least annually for those without kidney problems and weekly to monthly for patients with compromised kidney function. The medication can cause side effects including skin rash, nausea, and vomiting, particularly with extended use.
Antibiotic stewardship principles require healthcare facilities to ensure antibiotics are used appropriately and only when necessary. This includes regular assessment of whether the medication remains clinically indicated and monitoring for both therapeutic effectiveness and adverse reactions.
The consultant pharmacist interviewed during the inspection emphasized that staff should have been "monitoring for signs and symptoms of UTI to ensure the antibiotic is working as a prophylaxis" and following up with physicians about the prolonged use to "reduce adverse effects and improve resident outcomes."
Confusion Among Staff About Medication Classification
The inspection revealed concerning gaps in staff knowledge about the medication they were administering. During interviews, the facility's Infection Preventionist incorrectly stated that methenamine hippurate "is not an antibiotic" and was instead "antibacterial," demonstrating confusion about the medication's classification and monitoring requirements.
This misunderstanding had direct implications for patient care. The Infection Preventionist told inspectors they "did not do any monitoring for signs and symptoms of UTI" because they viewed the medication as antibacterial rather than antibiotic, despite the facility's own antibiotic stewardship policies requiring such oversight.
The consultant pharmacist clarified that methenamine hippurate is indeed classified as an antibiotic and requires the same monitoring protocols as other antimicrobial agents. This discrepancy in understanding among key clinical staff highlighted systemic issues with medication management education and protocol implementation.
Antibiotic Stewardship Program Deficiencies
The facility's antibiotic stewardship program, designed to ensure appropriate antimicrobial use, failed to capture this case of prolonged antibiotic therapy without adequate monitoring. The program's policy, last reviewed in June 2024, indicated that the consultant pharmacist should include medication safety criteria in monthly reviews, including "appropriate doses" and "durations of therapy."
However, despite this resident being on methenamine hippurate for over 16 months, the stewardship program did not flag the case for review or ensure proper monitoring protocols were in place. This represented a significant gap between written policies and actual implementation.
Following the inspection findings, facility leadership acknowledged the deficiencies and committed to program improvements. The Infection Preventionist stated that moving forward, they would "screen residents on methenamine hippurate as a prophylaxis for UTI for antibiotic stewardship program" and implement monitoring for signs and symptoms of UTI.
Clinical Risks and Patient Safety Implications
The lack of proper monitoring created several potential risks for the resident. Without regular assessment of UTI symptoms, staff could not determine whether the preventive medication was working effectively or if the resident was experiencing breakthrough infections that required different treatment approaches.
Prolonged antibiotic use without monitoring increases the risk of antibiotic resistance, where bacteria adapt and become less responsive to treatment. This can make future infections more difficult to treat and potentially more dangerous for vulnerable nursing home residents.
Additionally, the absence of kidney function monitoring meant that potential medication-related kidney damage could go undetected. This is particularly concerning for elderly residents who may already have compromised kidney function and are at higher risk for medication-related complications.
The Director of Nursing acknowledged during the inspection that "staff should have monitored for signs and symptoms of UTI on Resident 37 while using methenamine hippurate to know if the medication is effective or not" and should have contacted the physician for monitoring orders if none existed.
Industry Standards and Best Practices
Federal regulations require nursing facilities to ensure each resident's drug regimen is free from unnecessary medications and that all prescribed drugs are monitored for effectiveness and adverse reactions. The Centers for Medicare & Medicaid Services emphasizes that facilities must have robust medication management systems that include regular review of long-term therapies.
Best practices for antibiotic stewardship in long-term care settings include regular medication reviews, clear documentation of therapeutic goals, and systematic monitoring for both desired effects and adverse reactions. Facilities should also ensure that all clinical staff understand the medications they're administering and the associated monitoring requirements.
The case highlights the importance of ongoing staff education about medication classifications and monitoring protocols, particularly for medications that may be prescribed for extended periods in vulnerable populations.
Additional Issues Identified
The inspection also revealed broader concerns about the facility's medication management processes, including gaps in staff knowledge about antibiotic classifications and insufficient implementation of existing stewardship policies. The facility's response included commitments to enhanced screening procedures and improved communication with prescribing physicians about long-term antibiotic use.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Santa Clarita Post-acute Care Center from 2025-02-14 including all violations, facility responses, and corrective action plans.
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