Failure to Maintain and Monitor Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program (IPCP) as required. Specifically, the facility did not conduct an annual review and update of its IPCP standards, policies, and procedures. The last documented review and update occurred over a year prior, and the IPCP manual had not been reviewed or updated by the expected date. The Infection Preventionist (IP) confirmed that the manual in use was outdated and that the required annual review involving the Medical Director, DON, and IP had not taken place. Additionally, the facility did not have a comprehensive or current policy regarding COVID-19 vaccination for residents. While the policies addressed influenza and pneumococcal vaccinations, there was no documented procedure for COVID-19 vaccination. The IP acknowledged the absence of a COVID-19 immunization policy and stated that one should be in place. The process for offering and administering vaccines was described, but there was no monitoring system in place to ensure residents who consented to vaccination actually received them in a timely manner. An audit initiated by the IP after the survey began revealed that several residents who had consented to influenza, pneumococcal, and COVID-19 vaccines had not received them as requested or within the appropriate timeframe. Specifically, four residents did not receive the influenza vaccine, nine did not receive the pneumococcal vaccine, and eleven did not receive the COVID-19 vaccine, despite having provided consent. Some of these residents had been in the facility for over a year and were not up to date on vaccinations. The IP confirmed that the lack of policy development, monitoring, and timely administration of vaccinations contributed to the deficiency.