Failure to Maintain Infection Surveillance and Documentation
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program as required. Specifically, there was no documentation of a surveillance plan for tracking or monitoring infections, communicable diseases, and outbreaks among residents and staff for the entire year of 2024 and the months of January and February 2025. The facility's policy required routine monitoring and surveillance, including the use of standardized assessment tools and regular reporting to the QAPI committee. However, interviews revealed that the infection preventionist identified infections based on resident symptoms and physician input, but there was no evidence of systematic infection tracking or trending prior to April 2025. Further investigation found that the previous Assistant Director of Nursing, who also served as the infection preventionist, left the facility in March 2025 and took the infection control records with her. As a result, the facility was unable to produce any infection control data for the period before April 2025, despite attempts to retrieve the information. While clinical meetings and antibiotic reviews were conducted, and infection numbers were presented in QAPI meetings after April 2025, there was a lack of documented infection surveillance and reporting for the earlier period, constituting noncompliance with infection control requirements.