Incomplete Infection Surveillance Documentation and Lack of Program Continuity
Penalty
Summary
The facility failed to provide complete documentation of an infection surveillance plan as part of its Infection Prevention and Control Program (IPCP). Record review revealed the IPCP lacked procedures for staff to monitor residents for possible infections and communicable diseases, early detection and management of symptomatic residents requiring laboratory testing, implementation of transmission-based precautions and PPE, and tracking this information in an infectious disease log. Additionally, there was no evidence of an evidence-based surveillance system or data collection tool, nor was there documentation of ongoing analysis of surveillance data or follow-up activities. Interviews with facility leadership indicated a lack of continuity and awareness regarding the IPCP. The Administrator stated that infection surveillance was implemented but could not provide further details. The Interim DON and the Infection Control Preventionist, both new to their roles, reported not receiving any documentation or guidance from the previous DON regarding infection surveillance efforts. The Medical Director was also unaware of his responsibilities in implementing and maintaining an infection surveillance plan and noted that he was only contacted by the facility as needed, without regular meetings or coordination.