Inaccurate Infection Surveillance Documentation and Incomplete Data Collection
Penalty
Summary
The facility failed to implement its infection prevention and control program as required, specifically by not ensuring the accuracy and completeness of its monthly Infection Prevention and Control Surveillance Log and Surveillance Data Collection Forms. For the months of January and February 2025, the numbers recorded on the surveillance logs did not match the infection control monthly summary reports, resulting in inaccurate reporting of healthcare-associated infections (HAIs), community-acquired infections (CAIs), and infections not meeting McGeer's criteria. This discrepancy was confirmed by both the Infection Preventionist (IP) and the Director of Nursing (DON) during interviews and document reviews. Additionally, the Surveillance Data Collection Forms for several residents who received antibiotics for infections were incomplete, as they failed to indicate whether the infections were classified as HAI or CAI, despite documentation of antibiotic administration and McGeer's criteria assessment. The IP acknowledged that these forms were incomplete and that the infection data should have matched across all reports to ensure accurate infection control information. The DON also verified and acknowledged these findings during the review.