Deficient Infection Surveillance and Documentation During Outbreak
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by incomplete and inaccurate infection surveillance processes from January 2025 through May 2025. The infection surveillance line lists reviewed by the surveyor were missing critical data each month, including well dates, details on resident and staff isolation, onset of symptoms, types of laboratory tests completed, and the rationale for antibiotic use. Additionally, there was a lack of documentation regarding the location of infections, staff-resident contact tracing, and summary or analysis of infection outbreaks, specifically during an Influenza A outbreak in February 2025. During interviews, the Director of Nursing (DON) acknowledged that infection logs and outbreak data were combined into a single spreadsheet, but could not provide comprehensive documentation or summaries related to outbreaks or infection control activities. The DON also admitted to not maintaining records of staff infections and surveillance after the previous DON left the position. The Assistant Director of Nursing (ADON) reported using McGeer's criteria for infection identification but did not document whether criteria were met, and there was an instance where a resident diagnosed with a UTI and prescribed antibiotics was not included in the infection line list for that month. The facility's infection surveillance logs lacked documentation of follow-up actions in response to surveillance findings, such as outbreaks, and did not include observations of staff practices or identification of ineffective infection control measures. The absence of thorough and accurate infection surveillance, incomplete documentation, and lack of analysis or summary of infection control activities contributed to the deficiency, with the potential to affect all residents in the facility.