Deficient Infection Control Program and Incomplete Surveillance Documentation
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in staff illness tracking, resident infection surveillance, and adherence to hand hygiene protocols. One staff member returned to work less than 48 hours after experiencing gastrointestinal symptoms, contrary to CDC guidelines and facility policy, which require exclusion from work for at least 48 hours after symptom resolution. Additionally, the staff illness line list used for infection surveillance was incomplete, with five staff members missing the date of last symptoms, making it difficult to determine appropriate return-to-work timing and to conduct accurate illness tracking. Resident infection surveillance was also found to be deficient. For two residents, the infection line list did not accurately reflect their symptoms or infection details. One resident with a urinary tract infection had missing or incorrect information on the line list, including the onset date, symptoms, and laboratory results, and the infection was not recorded in the appropriate month. Another resident's line list entry did not match the information documented on the McGeer Criteria checklist, with discrepancies in symptoms and infection criteria. These inaccuracies in documentation hindered the facility's ability to conduct effective infection surveillance. Furthermore, staff did not consistently perform appropriate hand hygiene during resident care. During an observation of catheter care, a certified nursing assistant changed gloves four times without performing hand hygiene between glove changes, despite facility policy and standard practice requiring hand hygiene before donning and after removing gloves. The staff member acknowledged the expectation for hand hygiene but did not adhere to it during the observed care. These failures in infection control practices had the potential to affect all residents in the facility.