Failure to Implement Infection Surveillance in Infection Control Program
Penalty
Summary
Facility staff failed to implement an effective infection prevention and control program, as evidenced by the lack of a comprehensive infection surveillance system across all three nursing units. The infection preventionist (IP) was responsible for the program but only tracked residents who were treated with antibiotics, using an Antibiotic Use Tracking Sheet. No logs were completed for the current month, and the IP confirmed that surveillance was conducted retrospectively at the end of each month, rather than proactively. Residents who developed signs or symptoms of infection were not tracked unless they were prescribed antibiotics. During interviews, the IP acknowledged that the purpose of infection surveillance is to identify symptoms and trends to prevent the spread of infection, but admitted that no proactive tracking or documentation was in place. The IP stated that she reviewed the 24-hour report daily but could not provide evidence of infection surveillance. Review of the facility's policy confirmed that the IP was responsible for conducting surveillance of staff and residents for infections, but this was not being carried out as required. The administrator and DON were informed of these findings, and no additional information was provided.