Inadequate Oversight of Infection Prevention and Control Program
Penalty
Summary
The facility failed to ensure that the designated infection preventionist (IP) provided adequate oversight of the infection prevention and control program, as well as the antibiotic stewardship program. Review of monthly resident surveillance forms revealed incomplete documentation, including missing resolved dates and lack of columns for antibiotic time-outs or implementation of precautions. The IP only documented residents on antibiotics and did not include those who were ill but not receiving antibiotics. For staff surveillance, records showed that eight staff members returned to work before the recommended work restrictions for potential norovirus symptoms, and the required call-in forms were not consistently completed by charge nurses. The IP was unsure of her oversight responsibilities and had no documentation of follow-up when protocols were not followed. Interviews with the IP and the DON confirmed that the IP was not effectively monitoring or ensuring adherence to infection control policies and protocols. The DON expected the IP to provide oversight and education when protocols were not followed but was unaware that these duties were not being performed. Additionally, there was no evidence that the IP was being overseen by an infection control committee, as required by facility policy. The facility's infection prevention and control manual outlined specific surveillance and oversight responsibilities that were not being met, including comprehensive data collection, analysis, and reporting to the appropriate committees.