Failure to Maintain Comprehensive Infection Surveillance and Tracking
Penalty
Summary
The facility failed to implement an effective system of surveillance for infection tracking as required by its own Infection Prevention and Control Plan. The Infection Preventionist (IP), who was new to the role, was responsible for maintaining an up-to-date infection line listing but had not started the line listing for the month of April at the time of the survey. Instead, the IP relied on a monthly line listing that only tracked residents on antibiotics, which lacked several required data elements such as date of admission, date of onset of symptoms, specific signs and symptoms, and organism(s). Additionally, the line listing did not include resident room numbers, and some entries were incomplete, such as missing antibiotic information for certain residents. The facility maintained two separate tracking tools: a Line Listing for Antibiotic Use and an Infection Tracker Line Listing. The Infection Tracker Line Listing, which was intended to track all infections, also lacked critical information, including resident room numbers and specific signs and symptoms of infection. There were discrepancies between the two lists, with some residents appearing on one list but not the other, and the Infection Tracker Line Listing was not consistently updated by the Unit Managers as required. The DON acknowledged these gaps and stated that the Infection Tracker Line Listing should be used for all infections and that missing information was due to staff not entering data as expected. The facility's policies and infection control plan emphasized the importance of surveillance, including the collection and analysis of infection data to identify trends, clusters, and patterns. However, the lack of a comprehensive, up-to-date, and accurate infection line listing, as well as incomplete documentation of required information, resulted in inadequate monitoring and tracking of infections. This failure placed residents at risk for insufficient infection monitoring and potential spread of infections within the facility.