Failure to Implement Infection Control and Antibiotic Stewardship Programs
Penalty
Summary
The facility failed to establish and implement an effective Infection Prevention and Control Program (IPCP) and an Antibiotic Stewardship Program as required by regulation. Review of facility policies and records revealed that there were no protocols or systems in place to monitor and optimize antibiotic use, track infections, or analyze infection data. The facility lacked a line listing or infection tracing system, did not use an infection surveillance checklist, and failed to maintain or provide staff and resident immunization records, as well as data from the last COVID-19 outbreak. Additionally, the required antibiotic stewardship program policy, protocols, and committee documentation were not available for evaluation. Interviews with the Infection Control Preventionist Nurse (ICPN) and the Director of Nursing (DON) confirmed that the facility had not had an active Infection Control Program since July 2024, and that the current ICPN, who was newly hired and inexperienced in this role, had not yet implemented necessary tracking forms or established an antibiotic stewardship committee. The ICPN admitted to not maintaining an updated log of residents on antibiotics and was unaware of the full requirements for infection tracking and stewardship. The DON acknowledged awareness of the missing documentation and stated that previous records may have been lost or destroyed when the prior ICPN left, leaving the new ICPN to rebuild the program from scratch.