Failure to Maintain Complete Infection Surveillance Documentation
Penalty
Summary
The facility failed to maintain appropriate infection prevention and control practices, specifically in the area of surveillance documentation. Over a period from January to mid-June 2025, infection control records were incomplete, lacking critical information such as date of onset, symptoms, culture dates and results, re-culture dates, isolation status, resolution dates, and whether the infections met established criteria. This incomplete documentation was noted for multiple types of infections, including respiratory, urinary tract, skin, and blood infections, affecting all residents in the facility. Additionally, the facility's infection control book, which should have contained up-to-date surveillance and tracking information, was missing for a significant period. The absence of this documentation hindered the facility's ability to monitor infection patterns and trends, as evidenced by the lack of monitoring records on villa floorplans. Interviews with the DON, IP, and RDCO confirmed that the infection prevention binder was not maintained as required and had to be reconstructed retroactively for the first half of 2025. The facility's own infection prevention and control policy required a surveillance system capable of identifying and tracking communicable diseases, ensuring timely reporting, and implementing appropriate isolation measures. However, the lack of complete and current documentation meant that these policy requirements were not met, potentially impacting the facility's ability to prevent and control the spread of infections among residents and staff.