Infection Control Committee Lacked Required Multidisciplinary Attendance
Penalty
Summary
The facility failed to ensure that all required nine multidisciplinary members were present at the quarterly Infection Control Committee meetings for three out of four quarters. Specifically, attendance records for the first, second, and third quarterly meetings showed that the Medical Director, a laboratory representative, and a pharmacy representative were not present at various meetings. The facility's policy requires a risk assessment using an all-hazard approach to prioritize infection prevention and control activities, and these meetings are intended to support that process. Interviews with the Director of Nursing confirmed that the required members were not in attendance for the specified quarters. The absence of these key members was documented in the meeting attendance logs, and the deficiency was acknowledged by facility leadership during the survey process. No information about specific residents or their medical conditions was provided in the report.
Plan Of Correction
Required signatures couldn't be obtained since meetings have passed. Infection preventionist will have the Medical Director, lab, and pharmacy attend 1 meeting each quarter of the year. Director of Nursing or Designee will educate all team members of Infection Prevention on required meeting attendance. Director of Nursing or designee will audit the Infection Control meetings to assure all required attendance is met quarterly. Audit results will be turned into Quality Assurance meeting monthly.