Deficient Infection Surveillance and Hand Hygiene Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by inaccurate and incomplete infection surveillance and inadequate hand hygiene practices. The Infection Preventionist (IP), who also served as the Director of Nursing (DON), was responsible for infection surveillance using the McGeer criteria. However, the facility's surveillance documentation for several residents was found to be incomplete or inaccurate, with missing or insufficient signs and symptoms to meet the criteria for healthcare-associated infections (HAIs). Additionally, the facility was using outdated McGeer criteria from 2013, despite a more recent revision being available, leading to further inaccuracies in infection reporting. Specific examples included residents being counted as having HAIs without sufficient documentation of required symptoms or diagnostic evidence, such as chest x-rays for pneumonia or detailed signs for skin infections. In some cases, surveillance forms were left blank or lacked critical information, and the IP acknowledged errors and lack of awareness regarding updated surveillance criteria. The facility's infection control report sheets and surveillance records did not align with the most current standards, resulting in misclassification and under-documentation of infections. Observations by surveyors revealed that staff did not consistently perform hand hygiene when entering or exiting resident rooms, between meal tray passes, or when assisting residents with meals. Residents were not offered or encouraged to clean their hands before meals, and staff used regular napkins instead of designated hand wipes, which were reportedly out of stock. Staff interviews confirmed that hand hygiene protocols were not being followed, and the facility lacked a policy specifically addressing hand hygiene during meal pass and meal assistance. These lapses contributed to an environment that did not meet infection prevention and control standards.