Inadequate Infection Control Program Implementation
Penalty
Summary
The facility failed to maintain and implement a comprehensive infection prevention and control program as required by regulations. A review of the facility's policies and infection control logs revealed significant deficiencies in the program's execution. The facility's policy on 'Infection Prevention and Control Program' outlined the need to identify, investigate, control, and prevent infections, but the actual practice did not align with these objectives. Specifically, the facility lacked an effective system to analyze infection clusters, track changes in prevalent organisms, or identify increases in infection rates in a timely manner. Further investigation into the facility's infection control logs from May 2024 through March 2025 showed that there was no tracking of infections for June 2024. Additionally, the logs were incomplete, missing critical infection-related details such as the location of infections, whether they were community-acquired or facility-acquired, symptoms experienced by residents, and the onset date of infections. An interview with the Assistant Director of Nursing, who also serves as the facility's Infection Preventionist, confirmed the absence of a tracking log for June 2024 and acknowledged the incompleteness of the logs, indicating a failure to support a comprehensive infection prevention and control program.
Plan Of Correction
Facility logs for June 2024 were located and are present in the facility. Current system utilized for infection prevention and control will be reviewed. Processes not meeting policy guidelines will be updated and implemented. Nursing staff will be re-educated on facility infection prevention and control program and policies. Audits will be completed on new infections to determine that criteria in facility policies have been followed weekly x 4 weeks, then monthly x 2 months. Results will be reviewed in monthly QAPI meeting.