Failure to Track Candida auris and Educate Resident and Family Within Infection Control Program
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective infection prevention and control program for a resident with Candida auris, including failure to track the infection and failure to provide timely education to the resident and family. The resident was admitted with multiple diagnoses including type 2 diabetes with neuropathy, osteomyelitis of the left ankle and foot, and Candida auris, and had an order for Enhanced Barrier Precautions related to Candida auris that remained active until the resident was transferred to the hospital. The care plan documented that Enhanced Barrier Precautions would be maintained and included an intervention to educate the resident, family, and staff regarding these precautions. However, the medical record contained no evidence that the resident or resident representative received education on the infection, its treatment, or necessary precautions until a late entry close to the end of the resident’s stay. The resident was cognitively intact and required extensive assistance with mobility, ADLs, and use of a wheelchair, but there was no documentation that the resident refused family involvement in care or treatment. A care plan conference summary showed that the resident’s diagnoses and plan of care were reviewed, but the narrative section was blank and did not document any discussion of Candida auris, and there was no evidence that family members attended. Infection control logs for several months could not be produced, and an Infection Control Detail Report for a period in which the resident was on Enhanced Barrier Precautions did not list Candida auris for this resident. The facility was unable to demonstrate that the resident’s Candida auris status was tracked in the infection control program from late in the year through early the following year. Physician orders initially placed the resident on Enhanced Barrier Precautions for Candida auris and later changed to Contact Precautions, then back to Enhanced Barrier Precautions after a negative culture, but the record did not explain why the level of precautions changed or document a clear determination of infection versus colonization. Progress notes showed that the resident’s POA was contacted about Contact isolation and retesting for Candida auris, but the notes described the POA as verbally aggressive and did not document that the POA received clear education about the infection or precautions. Interviews with the DON, NP, PA, Medical Director, Regional Director of Clinical Operations, and former RN staff revealed confusion and lack of awareness about when Candida auris was first identified, why the resident was on lifelong precautions, and who was responsible for infection control oversight. The former RN reported discovering Candida auris in the chart, initiating Contact Precautions after consulting corporate, and notifying the family, who questioned why precautions were only then being implemented. The facility’s own resident rights policy and CDC guidance referenced the need for residents and representatives to be fully informed about medical conditions and for facilities to use consistent infection prevention and control measures for Candida auris, but the documentation and interviews showed that the facility did not consistently track the infection or ensure timely, documented education for the resident and family. Additional interviews further highlighted gaps in communication and documentation related to Candida auris. The DON and Administrator could not locate infection control logs for several months and could not confirm whether the resident’s Candida auris was tracked during that time. The Social Services Designee stated that the resident did not want his family involved in care conferences but acknowledged that this was not documented in the medical record. The PA who assumed care after a change in primary provider reported he was not informed of the resident’s Candida auris and saw no documentation about it when he took over care. The Medical Director stated he did not recall the Candida auris issue and did not believe a meeting was needed to discuss it. Collectively, the lack of infection control tracking, missing logs, absence of clear documentation of infection status and precaution rationale, and failure to document timely education to the resident and family led to the cited deficiency in the facility’s infection prevention and control program.
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