Failure to Document Hospital-Treated Pneumonia on Infection Control Log
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program by not including a resident diagnosed with pneumonia on the infection control log. The resident, a male with a history of Alzheimer's Disease, COPD, and acute respiratory failure, was admitted to the facility, sent to the hospital after a chest x-ray indicated possible pneumonia, and subsequently diagnosed with pneumonia and sepsis at the hospital. Upon return to the facility, the resident was not added to the infection control log, despite the diagnosis and treatment for pneumonia. The Director of Nursing, who also served as the infection preventionist, acknowledged awareness of the resident's pneumonia diagnosis and hospital treatment but did not update the infection control log, stating that infections identified and treated outside the facility were not logged. The facility did not have a policy specifying requirements for the infection control log, and the infection control policy provided only general guidelines for nursing procedures. The administrator deferred to the DON for infection control log procedures and was unsure about the requirements for documentation of infections diagnosed during hospital stays.