Failure to Implement Comprehensive Infection Surveillance and Tracking
Penalty
Summary
The facility failed to implement appropriate tracking and surveillance of infections over a five-month period, as required by its own infection prevention and control policy. The policy specified that the Infection Preventionist should systematically collect, analyze, and interpret health data, including detailed information such as signs and symptoms, antibiotic use, and infection onset dates. However, reviews of infection tracking forms from January through April revealed missing critical data, such as signs and symptoms and antibiotic stop dates. Additionally, the number of infections recorded on the tracking forms did not match the number of residents receiving antibiotics according to pharmacy order reports, indicating incomplete or inaccurate surveillance. For May, no infection tracking documentation was available at all. Interviews with the Director of Nursing confirmed that the facility did not have complete infection surveillance, including the tracking of signs and symptoms. The discrepancies between the infection tracking forms and pharmacy order reports, as well as the absence of required documentation, demonstrate a failure to follow established infection surveillance protocols. This deficiency was cited under 28 Pa. Code 211.10(d) Resident care policies and 28 Pa. Code 211.12(d)(1)(5) Nursing services.