Failure to Implement Effective Infection Surveillance and Documentation
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. The policy required the Infection Control Committee to investigate, control, and prevent infections, including performing surveillance and investigation to prevent the onset and spread of infection. However, review of the Antibiotic list for March and April 2025 showed that while residents were documented as being on antibiotic therapy for various infections, there was no documentation available for infection onset dates, signs and symptoms, laboratory or radiology results, isolation status, or outbreak potential. During interviews, the DON/Infection Preventionist confirmed responsibility for infection tracking and surveillance, and stated that the Antibiotic list served as the surveillance report. Upon further review, the DON/Infection Preventionist acknowledged that the list lacked critical documentation elements necessary for effective infection surveillance, such as infection onset date, clinical signs and symptoms, lab and radiology results, type of precaution, and assessment of outbreak potential.