Failure to Maintain Comprehensive Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain a comprehensive Infection Prevention and Control Program, as required by policy and regulatory guidelines. The Director of Nursing (DON) was initially identified as the Infection Preventionist but clarified that she did not hold this role and lacked the necessary infection control training and certification. Instead, a nurse from another facility, who also serves as an Administrator elsewhere, was designated as the Infection Preventionist and only present one day per week. This individual reported being unable to complete essential duties such as staff education due to limited time on-site and was unaware of residents on prophylactic antibiotics. The facility's infection surveillance and tracking practices were not fully implemented, as required by their own policy. Additionally, there were lapses in infection monitoring for residents on prophylactic antibiotics. One resident had a physician's order for Bactrim for urinary tract infection (UTI) prophylaxis, and another had an order for daily Cephalexin for prophylactic use. However, the medical record for the latter did not contain an assessment or care plan to support the use of a prophylactic antibiotic. The Regional Nurse Consultant was unable to locate documentation justifying this antibiotic use. These deficiencies in infection prevention oversight and documentation had the potential to affect all 63 residents in the facility.