Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program as required, resulting in the absence of a system for identifying, tracking, monitoring, and reporting infections, communicable diseases, and outbreaks among residents and staff. Despite having a policy that outlines the responsibilities of the Infection Preventionist (IP) and nursing staff for ongoing surveillance, documentation, and reporting of infections, the facility was unable to provide any documented evidence of infection surveillance activities, line listings, or reporting data for an extended period covering several months. During the survey, the facility could not produce records or documentation related to infection tracking or follow-up activities in response to active antibiotic use, even though electronic records showed multiple antibiotic prescriptions for various infections over several months. Interviews with the DON and IP revealed that they were unaware of infection rates, lacked surveillance data, and did not have information on tracking, trending, or outbreak management. The DON stated reliance on verbal reports from nursing staff and admitted to having no data available, while the IP could not provide evidence of an infection prevention program, including antibiotic stewardship or vaccination tracking. Further, the Administrator acknowledged that the infection control program should be implemented and followed but was not aware of the current infection status in the facility, expecting clinical staff to manage these issues. The Medical Director, who started recently, confirmed the absence of an infection control program and stated that monitoring, tracking, and reporting of infections, as well as antibiotic stewardship and vaccination, were not being conducted as expected. No documentation was available to demonstrate compliance with infection prevention and control requirements.