Incomplete Infection Surveillance Documentation and Lack of Trend Analysis
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program as required by its own policy and national standards. Review of the infection control line listings for January, February, and March 2025 revealed that critical information was missing from the documentation. Specifically, the 'signs and symptoms' column was left blank for a significant number of infections each month, and the 'organism' column was incomplete for several urinary tract infections. This incomplete documentation hindered the facility's ability to accurately track and monitor infections among residents. During an interview, the Infection Preventionist (IP) confirmed that the facility uses McGeer's criteria to determine if a suspected infection qualifies for treatment, which requires documentation of specific signs and symptoms. The IP acknowledged that the facility does not document treatment outcomes or analyze trends to identify potential sources or patterns of infection spread, such as specific rooms or staff members. The IP also stated that all columns in the line listings should be completed to ensure accurate infection tracking, and that outcomes and trends should be identified and addressed, but this was not being done.