Failure to Track Infectious Organisms in Infection Control Program
Penalty
Summary
The facility failed to establish and implement an effective infection prevention and control program as required by its own policies and procedures. Specifically, the Infection Preventionist/Director of Nursing (IP/DON) did not track the specific organisms being treated within the facility, nor did she monitor for outbreaks or cross-contamination. Policy documents reviewed indicated that surveillance should include identification of epidemiologically significant organisms, collection of data such as resident name, room number, unit, date of onset, infection site, and pathogens. However, infection control monitoring documents for several months did not include documentation of the organisms being tracked. During an interview, the IP/DON confirmed that she does not track organisms in the infection control program and was unable to provide documentation that such tracking was occurring. This lack of organism tracking and monitoring for outbreaks had the potential to affect all seven residents in the facility, as it hindered the facility's ability to identify, report, investigate, and control infections and communicable diseases as outlined in their policies.