Deficient Infection Control Program and Incomplete Surveillance Documentation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in infection surveillance, outbreak management, and sanitary medication administration practices. Observations revealed that a nurse prepared medications for a resident and, after dropping a pill onto the top of the medication cart, picked it up and administered it to the resident. The nurse stated that the cart had been cleaned at the start of her shift, but the DON confirmed that the top of the medication cart is not considered a clean surface and that the medication should have been discarded, as administering it posed an infection control concern. A review of the facility's infection surveillance documentation showed significant gaps and inconsistencies. Monthly infection line listings were incomplete, frequently missing critical information such as signs and symptoms of illness, dates of symptom onset, and culture results. Some laboratory results indicating the presence of significant pathogens were not included in the surveillance records. Additionally, the facility failed to track suspected infections that were not treated with antibiotics and did not maintain surveillance line listings for several months. The Infection Prevention Nurse acknowledged that the current system did not capture all necessary data, including symptoms, onset dates, and results from outside laboratories. The facility also failed to properly document and manage a COVID-19 outbreak. Although a significant number of residents tested positive for COVID-19 over a period of time, the facility did not maintain adequate records of outbreak investigation, contact tracing, or testing logs for staff and residents. The Infection Prevention Nurse was unable to provide documentation of who had been exposed, when testing occurred, or the results of staff testing. The only documentation available was a line listing of COVID-19 positive residents, which lacked information on symptoms and dates of onset.