Failure to Implement Infection Control Surveillance and Reporting During GI Outbreak
Penalty
Summary
The facility failed to implement its infection prevention and control program as required by policy and regulatory standards. Specifically, the facility did not establish or execute an effective infection control surveillance plan for identifying, tracking, monitoring, or reporting infections, communicable diseases, and outbreaks among residents and staff. Review of the facility's infection control policies indicated that the Infection Preventionist (IP) is responsible for tracking and monitoring infections, investigating outbreaks, and reporting communicable diseases to health authorities. However, documentation for March 2025 showed that the infection control line listing was incomplete, lacking critical information such as infection source (nursing home, hospital, or community acquired), isolation type, antibiotic use, and laboratory results. The line listing fields were left blank, and there was no surveillance information or outbreak identification plan documented for the gastrointestinal (GI) outbreak that occurred during that month. Interviews with the IP and the DON confirmed that the GI outbreak, which affected 20 residents and 8 employees with symptoms of nausea, vomiting, and diarrhea, was not reported to the local health department, and no cultures were obtained to test for Norovirus. The IP stated she did not have information on how the outbreak started, nor on the measures implemented or surveillance conducted during the event. The DON acknowledged that the outbreak should have been reported and documented, and that appropriate tracking and communication with health authorities did not occur. These failures represent a breakdown in the facility's infection prevention and control program as outlined in their own policies.