Failure to Implement Infection Control Program and Timely Notification for CRAB Exposure
Penalty
Summary
The facility failed to implement its Infection Prevention and Control Program (IPCP) for 27 residents following notification from the Local Health Officer's Public Health Nurse (PHN) that a resident tested positive for Carbapenem-Resistant Acinetobacter baumannii (CRAB) Tier 2, a rare and communicable multidrug-resistant organism. Despite receiving an email with recommendations from the PHN, the Director of Nursing (DON) did not initiate surveillance tracking or interventions for the 26 potentially exposed residents, nor did the facility notify the California Department of Public Health (CDPH) within the required 24-hour period. The DON acknowledged being too busy and covering for the infection preventionist at the time, resulting in a delay of 11 days before screening exposed residents was initiated. Additionally, the facility did not notify the primary medical doctor of the resident who tested positive for CRAB, nor did it notify or coordinate with the attending physicians of the 26 other residents who were potentially exposed and recommended for rectal swab screening. There was no documentation in the affected residents' medical records regarding the exposure, the positive CRAB result, or the recommended screenings. The infection preventionist, who started after the initial notification, confirmed that attending physicians were not informed and that there was no documentation or change of condition forms completed for the exposed residents. The facility's own policies and procedures require immediate notification of attending physicians for significant changes in condition, surveillance and data reporting for infection control, and reporting of unusual occurrences to appropriate agencies within 24 hours. These policies were not followed, as evidenced by the lack of timely surveillance, physician notification, and reporting to CDPH. Interviews with facility staff and the PHN confirmed these failures, and the DON admitted that the lack of action could have allowed the communicable disease to spread and prevented residents from receiving appropriate medical recommendations.