Infection Control Deficiencies and Reporting Failures
Penalty
Summary
The facility failed to meet the minimum standards for infection control as required by state regulations and the MCARE Act. Specifically, the facility did not ensure that all required multidisciplinary members were present at the Infection Control Committee meeting for one of the four quarters, as the laboratory member was absent during Quarter Four. Additionally, the facility did not report healthcare-associated infections for January and February 2025, despite having recorded six infections in January and seven in February. This failure was attributed to the transition of the Infection Preventionist role, where the new Regional Clinical Director-Infection Preventionist did not have the necessary access to report these infections. Furthermore, the facility did not provide written notification to residents or their family members within seven days of a healthcare-associated infection for the months of January and February 2025. This lack of communication was confirmed by the Infection Preventionist, who acknowledged that no letters had been sent to the residents or their families during this period. These deficiencies highlight the facility's non-compliance with the MCARE Act's requirements for infection control and timely communication with residents and their families.
Plan Of Correction
Moving forward, the facility will ensure that the required multidisciplinary members are present at the Infection Control meeting. The facility will report health care associated infections monthly and will provide written notification to the resident/family member of a healthcare-associated infection. To prevent this from recurring, the RVPO/RDCS educated the IP on requirements of 1020 and the responsibility of the licensee. The facility will ensure the appropriate team members are present at the meetings. To monitor and maintain ongoing compliance, the RDCS/designee will audit infection control/PASRS reporting weekly for 4 weeks, then monthly for 2 months. Negative findings will be addressed, and ad hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.