Failure to Track Infections, Antibiotic Use, and Complete Required TB Testing
Penalty
Summary
The facility failed to ensure proper implementation of its infection prevention and control program, specifically in tracking infections, antibiotic use, and conducting required tuberculin (TB) testing for residents. Review of medical records revealed that several residents did not have evidence of a second TB test administered within the required timeframe after admission, and in some cases, there was no documentation of TB test results being read or of annual TB testing being completed. The Director of Nursing, who also served as the Infection Preventionist, acknowledged responsibility for overseeing immunizations and TB testing, and confirmed that two initial TB tests are required upon admission unless contraindicated. Additionally, the facility's infection control program lacked documentation of antibiotic tracking or infection surveillance for a period of several months, specifically from May to November of the previous year. Although the facility had policies in place requiring ongoing surveillance for healthcare-associated infections and routine tracking of antibiotic use, these procedures were not followed during the specified period. The DON indicated that infection tracking began only after her employment started in December, leaving a gap in compliance with infection control protocols.