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F0880
D

Failure to Track Pathogens in Infection Control Reports

Murfreesboro, Tennessee Survey Completed on 07-01-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow its own infection control practices by not tracking pathogens in its monthly Infection Control 2025 reports, as required by its policy on antibiotic stewardship and surveillance. The policy specifies that antibiotic usage and outcome data, including the identified pathogen and date of culture, must be documented using a facility-approved antibiotic surveillance tracking form. However, a review of the Infection Control 2025 reports for three consecutive months showed that there was no column or documentation of the pathogen being tracked. During an interview, the Infection Preventionist/DON confirmed that pathogens were not being tracked in these reports. This deficiency potentially affected all 27 residents in the facility.

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