Failure to Implement Comprehensive Infection Control Program During COVID-19 Outbreak
Penalty
Summary
The facility failed to develop and implement a comprehensive infection prevention and control program, as evidenced by inadequate monitoring of antibiotic use, poor documentation and maintenance of infection surveillance during a COVID-19 outbreak, and improper infection control practices across both units. An Infection Control Assessment and Response Report (ICAR) by the Florida Department of Health identified that frontline staff had not received sufficient training on the use of disinfectants for different isolation precautions, resulting in the use of incorrect cleaning agents in rooms under transmission-based precautions. Additionally, access to hand sanitizer was limited, and there was confusion regarding the use of EPA-approved disinfectants for specific pathogens. Interviews revealed that housekeeping staff were uncertain about the chemicals they were using, with one housekeeper admitting to using mislabeled bottles and lacking knowledge about infection control practices and expectations. The housekeeper also reported inconsistent availability of personal protective equipment (PPE) and a lack of formal education on transmission-based precautions or posted signage. The Housekeeping Director confirmed that staff had not received formal infection control education from the facility and acknowledged confusion regarding the appropriate use of disinfectants, which was only corrected after the Department of Health's visit. Further review of facility records showed significant gaps in infection surveillance and antibiotic stewardship documentation, with missing reports for several months during the outbreak period. The Infection Control binder lacked documentation of the Department of Health's visit, recommendations, or follow-up actions. Leadership changes and lack of staff accountability contributed to these deficiencies, and the Unit Manager and Administrator were unaware of key recommendations and did not attend relevant meetings. The facility also failed to convene a Quality Assurance and Performance Improvement (QAPI) meeting to address the identified infection control deficiencies.