Failure to Accurately Calculate and Analyze Infection Rates
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by inaccurate calculation and analysis of infection rates. The Director of Nursing (DON), who oversees the infection control program, reported that individual rates of infection were not calculated, and infections were counted in multiple months if they persisted or were chronic. Additionally, the DON did not distinguish between facility-associated and community-based infections when compiling infection data. Monthly infection surveillance reports reviewed from October 2024 to March 2025 only included the number of infections, without calculations for each type of infection, and combined both community and facility-associated infections in the total rates. Further review of the facility's infection surveillance logs revealed that infections from previous months and chronic infections, such as those due to multiple drug-resistant organisms, were included in the infection rates. When asked, the DON was unable to provide a facility policy or standard practice for calculating infection rates. The surveyor notified the Nursing Home Administrator and the DON of these findings, and no additional information or justification was provided for the lack of proper infection rate calculations or the failure to use only new, healthcare-associated infections in the infection rate data.