Infection Control Program Deficiencies and Lapses in Surveillance, Staff Illness Tracking, and Daily Practices
Penalty
Summary
The facility failed to maintain a current and effective infection prevention and control program, as evidenced by incomplete and inconsistent infection surveillance logs, lack of data analysis, and insufficient tracking of infections and staff illnesses. Infection surveillance logs from January to March 2025 were missing critical information such as dates of symptom onset, details of implemented precautions, symptoms, culture results, and documentation of antibiotic time outs (ATO). In several cases, there was no evidence that appropriate cultures were taken, that the appropriateness of antibiotic therapy was evaluated, or that follow-up was conducted to determine if infections resolved or if treatment needed to be altered. The infection preventionist (IP) reported being unable to provide adequate oversight due to multiple competing responsibilities and insufficient time, and the director of nursing (DON) was unaware of the requirement for antibiotic time outs. Employee illness surveillance was also deficient. For example, a staff member diagnosed with Strep throat worked while symptomatic and returned to work without documentation of meeting CDC-recommended criteria for return, such as being fever-free and having received antibiotics for the appropriate duration. The facility lacked a policy specifying when staff should be excluded from work or the criteria for returning to work after illness. The infection control policy had not been updated since 2022 and did not reflect current standards or include necessary procedures for employee health surveillance. Additional infection control lapses were observed in daily practices. Staff were seen transporting soiled linens without proper bagging, allowing them to come into contact with their clothing and the environment, despite being aware of the correct procedure. In another instance, a nurse cleaned a resident's glucometer with an alcohol wipe instead of an EPA-approved disinfectant wipe, contrary to manufacturer recommendations and facility policy. The facility's policy on glucometer cleaning was vague and did not specify the required cleaning product. These failures in infection control practices and oversight had the potential to affect all residents in the facility.