Delayed Infection Control Measures Lead to Spread of Gastrointestinal Symptoms
Penalty
Summary
The facility failed to timely implement effective interventions to prevent the spread of infections among residents. The deficiency was identified through a review of clinical records, facility policy, infection control documents, and staff interviews. Specifically, 15 residents exhibited gastrointestinal symptoms such as vomiting and diarrhea over several days, starting from January 2, 2025. Despite the early onset of symptoms, the facility did not initiate documented infection prevention interventions until January 6, 2025. This delay allowed the symptoms to spread to additional residents across different units. The facility's Infection Preventionist (IP) had assumed the role in mid-December 2024 and was still acclimating to the position. During the weekend when most symptoms were reported, the IP was not on duty, and a consultant nurse was primarily responsible for infection prevention duties. The IP became aware of the situation upon returning to work on January 6, 2025, and conducted in-service training on the D Unit. However, the IP could not explain why interventions were not initiated earlier, specifically on January 3, 2025, when the symptoms began.
Plan Of Correction
- A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11, A12, A13, A14 and A15 ERS completed on 1/8/2025. - House audit completed to determine any other outstanding infection control issues related to reporting and any other infection control issues pertaining to the tag that was identified. - Policy entitled, "Infection Control", reviewed for any updates. - Re-education provided to all staff on facility policy. - The DON or designee will conduct weekly and PRN Infection Control audits x 4, then monthly x 2. - Audits will be presented at the monthly QAPI committee for ongoing oversight.