Failure to Maintain Infection Control Surveillance Documentation
Penalty
Summary
The facility failed to maintain documentation of its infection control surveillance records, affecting all 73 residents. During a review of the Infection Control Binder (ICB), surveyors found that it contained infection control surveillance data only for January through March 2026, with no records for any months prior to January 2026. In an interview, the Infection Prevention Nurse stated she did not believe she was required to retain infection control surveillance information and had been discarding each month’s surveillance records at the beginning of the following month. She also noted that the last annual survey had occurred in December 2024. In a separate interview, the Region Nurse Consultant reported that monthly infection control surveillance documents should have been kept in the ICB from one annual survey until the next and confirmed that the facility did not have a policy for maintaining infection control surveillance information. No specific resident medical histories or conditions at the time of the deficiency were described in the report, only that 73 residents resided in the facility and were potentially affected by the lack of retained infection control surveillance documentation.
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