Inadequate Infection Prevention Oversight and Documentation
Penalty
Summary
The facility failed to ensure that the designated infection preventionist (IP) had sufficient time and competency to oversee the infection prevention and control program. The IP was responsible for multiple duties, including wound care, supply ordering, and occasionally working floor shifts, which limited her ability to focus on infection control tasks. The IP reported not having enough time to complete her infection control responsibilities and lacked documentation of competencies related to oversight of the infection control program. Surveillance logs maintained by the IP were incomplete, missing critical information such as infection onset dates, symptoms, culture results, antibiotic time outs (ATO), and follow-up on the effectiveness or appropriateness of prescribed antibiotics. The IP only documented infections treated with medication and did not monitor all infections as required. Multiple instances were identified where residents with infections did not have complete documentation regarding cultures, causative organisms, isolation precautions, or ATOs. For example, one resident was prescribed antibiotics for both a viral and bacterial infection without clear justification, and another resident with a surgical site infection was not placed on enhanced barrier precautions upon return from the hospital. There was also a lack of evidence that the facility followed up on culture results or communicated with providers regarding antibiotic appropriateness. Additionally, the facility's antibiotic stewardship policy did not specify how the IP should monitor or communicate with providers about antibiotic use, and there was no evidence that the policy had been updated since 2022 to reflect current standards. Employee infection surveillance was also deficient. An employee diagnosed with Strep throat worked while symptomatic and returned to work without documentation of meeting criteria for return, such as being fever-free and having received antibiotics for the recommended period. The facility lacked a policy specifying when staff should be excluded from work due to infection. Observations revealed improper handling of soiled linens, with staff failing to bag contaminated items before transport, increasing the risk of cross-contamination. Staff interviews confirmed awareness of proper procedures but admitted to not following them due to being in a hurry. The director of nursing was unaware of the requirement for antibiotic time outs, and the infection preventionist had not performed or documented any such reviews.