Failure to Maintain Infection Surveillance and Isolation During Influenza Outbreak
Penalty
Summary
The facility failed to maintain an effective system for communicable disease surveillance and infection control during an influenza outbreak. Two residents who were roommates remained in the same room after one tested positive for influenza, while the other was not tested, despite having a primary diagnosis that placed him at higher risk for respiratory complications. There was no documentation of moving either resident to a different room or of testing the second resident for influenza. The infection preventionist and another key staff member were absent during the outbreak, and infection control responsibilities were delegated to other staff, but there were discrepancies and missing documentation regarding resident testing, isolation, and infection mapping. Record reviews revealed that the infection control binder lacked completed tracking and trending for the outbreak period, and the infection mapping for the relevant month was not done. The facility was unable to provide a complete infection control log for the outbreak period, and available lists did not document testing or isolation actions for the two affected residents. Facility policies required surveillance tools and transmission-based precautions, including private room placement or cohorting for residents with influenza, but these measures were not documented as being implemented.