Failure to Maintain Comprehensive Infection Surveillance and Trending
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program that included effective tracking and monitoring for infection trends, potentially affecting all 37 residents. Review of the infection control trending tools from 10/2025 to 03/2026 showed that the facility used a map with a color-coded key for different infection types (respiratory, gastrointestinal, UTI, wounds, and others), but there was no documentation of specific infection types or other details needed to identify patterns. This meant there was no evidence that infections were being trended in a way that would reveal patterns by type or location. Further review of the infection log from 12/2025 to 03/2026 showed that, after implementation of a new log, multiple UTIs and other infections were recorded without documentation of the causative organism or, in some cases, the site of infection. Specifically, in December there were four UTIs without organisms listed; in January, three UTIs without organisms; in February, seven UTIs without organisms and two infections without site or organism; and in March, one UTI without an organism. During an interview, the IP/LPN confirmed that infections were not being monitored for trends by type and that most UTIs did not have culture results to identify organisms, and reported having previously voiced concerns to the former DON but was told not to contact providers and to administer antibiotics as ordered. The facility’s infection control policy required investigation, monitoring, identification, control, and surveillance of infections, including completion of infection reports, obtaining antibiotic orders upon proper microorganism identification if necessary, updating the surveillance map with type and location of infections, and discussing patterns in weekly QA meetings, which was not reflected in the documented practice.
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