Deficient Infection Control Surveillance and Documentation for Eye Infections
Penalty
Summary
The facility failed to consistently maintain an ongoing infection control surveillance system and did not follow its own policy for the Infection Prevention and Control Program. Specifically, there were multiple instances where residents with eye infections did not receive timely treatment, and there was a lack of documentation regarding the reassessment of infection resolution and the effectiveness of prescribed treatments. For example, one resident with a history of acute and chronic respiratory failure, hemiplegia, and dysphagia was observed with bilateral conjunctivitis. There was a documented delay in the delivery and administration of prescribed antibiotic eye drops, and no follow-up assessment was recorded after the completion of the treatment. Additionally, the infection control surveillance documentation did not indicate whether the infection had resolved or if contact precautions were re-evaluated. Another resident experienced recurring eye infections and was prescribed multiple antibiotics and antifungal medications. Despite the implementation of contact precautions and new medication orders, there was no documentation of reassessment of the infection or the need for continued precautions after treatment completion. The infection control surveillance records also failed to accurately track and analyze all cases of eye infections, as some residents treated for infections were not included in the monthly mapping and analysis. The Infection Control Preventionist (ICP) and Director of Nursing (DON) interviews revealed inconsistencies in responsibility and documentation practices for monitoring infection resolution and discontinuing precautions. The facility's policy required surveillance activities to identify, investigate, control, and prevent the spread of infection, as well as documentation in the residents' electronic health records. However, the infection surveillance program did not reflect increases in eye infections, nor did it document educational interventions for staff when infection rates rose. The ICP stated that only facility-acquired infections were counted, and some ongoing infections were not documented if they carried over from previous months. These actions and omissions resulted in a deficient infection prevention and control program, as evidenced by incomplete surveillance, lack of follow-up, and inadequate documentation.