Failure to Implement Effective Infection Control for C. difficile and Surveillance
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically in the management of residents with confirmed or suspected Clostridioides difficile (C. difficile) infection. Housekeeping staff reported using cleaning products in contact isolation rooms that required specific contact times, but review of product labels and staff interviews revealed that none of the products in use were documented as effective against C. difficile. Additionally, there was confusion among staff regarding which products to use and their required contact times, and the Director of Nursing (DON) was unable to confirm the efficacy of products used on direct patient care equipment. The facility administrator later confirmed that the products being used were not effective against C. difficile infection. The facility also failed to properly identify and document possible communicable diseases or infections before they spread. Review of the infection surveillance report showed incomplete documentation, with missing signs and symptoms for numerous entries and a lack of categorization for infections. There was no documented infection surveillance plan, and staff were unable to provide evidence that effective infection surveillance was being performed. These deficiencies had the potential to affect 85 residents in the facility.