Failure to Implement Comprehensive Infection Control Program and Maintain Catheter Care Standards
Penalty
Summary
The facility failed to implement and operationalize a comprehensive infection prevention and control (IC) program, as evidenced by incomplete and inconsistent infection surveillance, inaccurate infection tracking, and lack of data monitoring and analysis. The IC LPN responsible for the program had less than a month of experience in infection control and was unfamiliar with key aspects of the role. Discrepancies were found between the infection mapping tool and the monthly infection control log, with infections missing or misclassified, and no system in place to track resident discharges, room changes, or carryover infections from previous months. Additionally, the facility did not track potential infections that were not treated with antimicrobials, and the IC LPN was unfamiliar with process surveillance and had not completed required audits. Further review revealed that antibiotic stewardship practices were not consistently followed. Several residents received antibiotics without appropriate culture and sensitivity (C&S) testing, and documentation was lacking regarding the rationale for antibiotic use when criteria were not met. In some cases, antibiotics were administered based solely on physician orders, without evidence of infection or proper risk versus benefit analysis. The facility's infection control policy required a system for monitoring antibiotic use, but this was not operationalized in practice. Direct observation of a resident with a urinary catheter revealed that the catheter drainage bag and tubing were repeatedly found lying on the floor, both inside and outside the privacy bag. The resident was unaware of the catheter's management, and staff who entered the room did not address the issue until prompted by a surveyor. When the LPN picked up the catheter from the floor, they did so without enhanced barrier personal protective equipment (PPE). These lapses in infection control practices created the potential for environmental contamination and the spread of infection among residents.