Failure to Maintain Comprehensive Infection Surveillance Line List
Penalty
Summary
The facility failed to establish and implement an effective infection prevention and control program as required by policy. Specifically, the facility did not maintain a comprehensive line list to monitor all residents for signs and symptoms of actual or potential infections. The documentation provided for the months of April, May, and June only included an infection control log with resident names, antibiotics ordered, and start and end dates, but lacked critical information such as residents' symptoms, lab results, imaging results, and whether residents met criteria for antibiotic use. Interviews with the Infection Preventionist and the Director of Nursing confirmed that there was no single, consolidated list tracking these details, and that information was instead dispersed across multiple lists and within the electronic health record. The facility's own policies require the Infection Preventionist to lead surveillance activities, maintain documentation of incidents and findings, and report surveillance outcomes to the Quality Assessment and Assurance Committee and public health authorities as needed. However, the absence of a comprehensive surveillance line list meant that the facility was not adequately tracking or trending residents' symptoms or potential infections. This deficiency had the potential to affect all 34 residents in the facility, as there was no systematic method in place to identify, report, investigate, or control infections and communicable diseases among residents, staff, volunteers, or others providing services.