Failure to Implement Infection Surveillance and Tracking Program
Penalty
Summary
The facility failed to implement an effective infection prevention and control surveillance program as required by its own policy. The facility's policy outlined the need for ongoing surveillance of healthcare-associated infections (HAIs) and other significant infections, including the collection of detailed data such as resident identifying information, diagnoses, admission dates, infection onset dates, infection sites, pathogens, and treatment measures. However, the facility relied on Order Listing Reports that only documented antibiotics prescribed and associated diagnoses, lacking critical information such as resident identifiers, admission dates, infection onset dates, and pathogen details. Additionally, the Infection Control Surveillance Binder did not contain line listings, infection tracking logs, or evidence of infection control tracking for staff, and did not summarize or analyze infection trends or patterns as required. Interviews confirmed that the Infection Control Surveillance Logs for both residents and staff had not been completed since July, following a change in the Director of Nursing. The interim and then permanent DON verified the absence of completed surveillance logs and tracking documentation. As a result, the facility did not have a functional system in place to identify, track, or monitor infections, communicable diseases, or outbreaks among its 27 residents and staff, as required by policy.