F0880

E

Failure to Accurately Track and Investigate GI Symptoms Under Infection Control Program

Oxford, Pennsylvania Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The facility failed to implement its infection prevention and control surveillance policies for residents with gastrointestinal (GI) symptoms. The written policy "Surveillance for Infection/Infectious Disease" required nursing staff to notify the charge nurse when residents had a temperature of 100°F or greater, two or more loose watery stools in 24 hours, skin inflammation or purulent drainage, or a hospital transfer due to infection, and required the DON or Infection Control (IC) Coordinator to enter such data on a Weekly Surveillance Line Listing Report to monitor trends. The "Outbreak Plan" policy required an outbreak investigation when there was evidence of a possible outbreak of an emerging infectious disease. Facility records showed that one resident had more than one loose bowel movement (LBM) in 24 hours on January 30, 2026, and seven additional residents on the Transitional Care Unit (TCU) had more than one LBM in 24 hours between February 1 and February 2, 2026, and these residents were listed on the Outbreak Case-Patient Line List.

However, nursing progress notes documented that another resident had two episodes of loose stools on two separate dates in early February 2026, and a different resident had multiple episodes of vomiting and multiple episodes of loose bowel movements, but these two residents were not included on the facility’s Outbreak Case-Patient Line List. During an interview, the IC nurse reported that residents with potential infectious symptoms were communicated to the DON during daily morning meetings or by verbal reporting and stated they only worked three days per week. The IC nurse explained that the previous DON initiated the GI symptom line list and then handed it off on February 2, 2026, but could not explain why the two additional symptomatic residents were not captured on the surveillance report and confirmed that no investigation was conducted to determine the source of the residents’ GI symptoms. The surveyors concluded that the facility failed to ensure appropriate surveillance, monitoring, and tracking for residents showing GI symptoms, citing 28 Pa. Code 201.18(b)(1), 211.5(f), and 211.12(d)(1)(3)(5).