Failure to Implement Infection Surveillance System
Penalty
Summary
The facility failed to implement a comprehensive infection prevention and control program, as evidenced by the lack of a functioning surveillance system to track and address infections and potential infections among residents, staff, and visitors. The Regional DON acknowledged that infection control activities had not been adequately completed and noted that a new staff member would be starting soon to address these issues. There was no documentation of a system for the prevention, identification, reporting, investigation, and control of infections and communicable diseases, nor was there evidence of an ongoing surveillance system based on national standards and the facility's assessment. Additionally, the facility did not maintain routine, ongoing, and systematic collection, analysis, interpretation, or dissemination of surveillance data to identify infections. The facility's own policy, revised in June 2024, outlined requirements for infection surveillance, including data collection on infection sites, pathogens, symptoms, resident locations, and analysis of infection trends. However, these activities were not documented or carried out, resulting in a failure to monitor adherence to infection prevention practices and to identify or address infection trends within the facility.