Failure to Maintain Infection Surveillance Documentation
Penalty
Summary
Facility staff failed to implement a complete infection prevention and control program for the months of November and December 2024. During this period, there was no evidence of an infection surveillance system in place to identify possible communicable diseases before they could spread within the facility. When asked, administrative and clinical leadership were unable to provide infection surveillance logs for the specified months, stating that both the director of clinical services and the current infection preventionist had only started their roles after the period in question and could not locate the required documentation. Interviews with the infection preventionist revealed that she began her role in mid-December 2025 and recalled a gastrointestinal issue affecting a few individuals, but no overarching trends or specific pathogens like Norovirus were identified. The infection preventionist described her current responsibilities for tracking infections and antibiotic usage, but this process was not in place or documented for the months under review. Facility policy requires ongoing surveillance for healthcare-associated infections, but no additional information or evidence of compliance for the deficient period was provided.