Infection Control Deficiencies: Inadequate Disinfection, Antibiotic Stewardship, and Legionella Surveillance
Penalty
Summary
The facility failed to maintain its infection prevention and control program as required by its own policies and CDC recommendations. During an observation, an LVN picked up a call light from the floor in a resident's room and placed it on the resident's bed without cleaning or disinfecting it, despite facility policy requiring such items to be cleaned after contact with the floor. The LVN acknowledged the oversight when informed, and the DON verified the incident. Additionally, the facility did not ensure that infection surveillance data for the antibiotic stewardship program was properly communicated to the physician. A resident was prescribed antibiotics for a suspected UTI, but the resident did not meet McGeer's Criteria for a true infection. There was no documentation that the physician was notified about the signs and symptoms or that the criteria for infection were not met, as confirmed by both the Infection Preventionist and the DON. The facility also failed to screen pneumonia cases for possible Legionnaire's disease, as required by its Legionella surveillance policy. Multiple cases of healthcare-associated pneumonia were identified over several months, but there was no coordination between the Infection Preventionist and the Maintenance Director regarding Legionella testing or discussion of pneumonia cases in infection control meetings. The last water system test for Legionella was conducted in the previous year, and the Maintenance Director only performed testing when instructed by the Administrator.