ELKO, NV - Federal health inspectors documented significant gaps in infection control oversight at Highland Manor of Elko during a July 2024 survey, finding that the facility's infection preventionist demonstrated inadequate competency in tracking disease spread and failed to maintain required antibiotic surveillance systems for the facility's 79 residents.
Critical Gaps in Infection Surveillance Systems
Inspectors identified substantial deficiencies in the facility's infection prevention program during the mid-July inspection. The infection preventionist, who also served as assistant director of nursing, could not produce current infection tracking data or antibiotic monitoring logs for July 2024 when requested by surveyors.
According to the inspection report, the facility's Antibiotic Stewardship binder completely lacked infections data, antibiotic use records, tracking information, room mapping, or trending analysis for the current month. When asked to provide this documentation on July 16, the infection preventionist explained that no tracking had been performed because the staff member had taken a three-day vacation earlier in the month.
The infection preventionist told surveyors that infection data was typically recorded in handwritten notebooks throughout each month, but confirmed that no such notebook had been started for July 2024. This meant that nearly halfway through the month, the facility had no documented record of which residents had developed infections or were receiving antibiotic treatment.
Infection surveillance serves as the foundation of any effective infection control program. Without current data on where infections are occurring, healthcare facilities cannot identify outbreak patterns, implement appropriate containment measures, or protect vulnerable residents from preventable disease transmission. The absence of this basic tracking for more than two weeks represents a fundamental breakdown in infection prevention protocols.
Confusion Over Medication Categories and Treatment Monitoring
The inspection revealed concerning gaps in the infection preventionist's understanding of basic pharmaceutical classifications. When surveyors requested a list of all residents currently receiving antibiotics on July 16, the staff member generated a report from the facility's electronic documentation system that was supposed to identify residents on antibiotic therapy.
However, the list contained significant errors. Of five residents identified as receiving antibiotics, only two were actually prescribed antibiotic medications. Two residents were receiving antifungal drugs, and one was taking an antiviral medication. Despite these discrepancies, the infection preventionist confirmed to surveyors that the provided list was accurate and complete.
This confusion between antibiotics, antifungals, and antivirals indicates a fundamental gap in pharmaceutical knowledge that directly impacts patient safety. Antibiotics treat bacterial infections, antifungals address fungal conditions like yeast infections, and antivirals combat viral illnesses. Each medication class works through different mechanisms and treats distinct types of infections. Inability to differentiate between these categories undermines the facility's capacity to monitor appropriate drug use and recognize potential treatment problems.
The Centers for Disease Control and Prevention requires nursing homes to track antibiotic use as part of their Antibiotic Stewardship Programs. These programs aim to ensure that antibiotics are prescribed only when necessary and that the correct medications are selected for specific infections. Proper tracking helps facilities identify overuse patterns, monitor for adverse reactions, and reduce the development of antibiotic-resistant bacteria.
Incomplete Infection Mapping and Trend Analysis
Surveyors documented that the facility's infection mapping system - designed to visually represent where different types of infections were occurring throughout the building - was not being maintained according to required standards. The infection preventionist explained that these maps were created at the end of each month to identify infection trends and patterns.
The July 2024 infection map had not been created as of the mid-month inspection date. Furthermore, the infection preventionist told surveyors that the mapping system only included residents currently taking antibiotics, which meant it omitted residents with infections not being treated with antibiotics.
This approach creates dangerous blind spots in infection surveillance. Residents may have infections that are being treated with other medication types, infections that are being monitored without medication, or conditions awaiting diagnosis. By excluding these cases from the tracking system, the facility lost the ability to recognize whether infections were spreading through specific areas of the building.
The infection preventionist acknowledged to surveyors that without a current infection map, the facility could not determine whether infections were being successfully contained or were spreading throughout the building. This represents a critical gap in outbreak prevention capabilities.
Infection mapping allows facilities to quickly visualize whether multiple residents in the same hallway or wing are developing similar symptoms, which could indicate person-to-person transmission or environmental contamination. Without this tool, facilities may miss early warning signs of outbreaks that require immediate intervention to protect other residents.
Lack of Documented Qualifications and Training
The inspection found that the facility had not established a specific job description for the infection preventionist role. According to the administrator's statements during the survey, the infection prevention responsibilities were considered part of the assistant director of nursing position rather than a distinct role requiring specialized qualifications.
The assistant director of nursing job description documented general responsibilities for supervising infection control and antibiotic stewardship programs. Specific duties included completing weekly infection control reports, reviewing infection and isolation numbers, monitoring wound documentation, and ensuring compliance with standard precautions and CDC isolation guidelines.
However, the inspection findings indicated that these responsibilities were not being fulfilled according to federal requirements. Federal regulations require infection preventionists to possess specific education and demonstrated competency in infection surveillance, outbreak investigation, and implementation of evidence-based prevention practices. The role demands specialized knowledge that goes beyond general nursing skills.
The CDC's Core Elements of Antibiotic Stewardship for Nursing Homes establishes seven essential components that facilities must implement. These include leadership commitment, clear accountability with designated leaders, access to staff with specialized training, implementation of policies to improve antibiotic use, tracking of antibiotic use and outcomes, and regular reporting of findings to clinical staff.
The inspection findings documented failures across multiple core elements. The facility lacked current tracking systems, could not produce outcome data, and demonstrated gaps in the specialized knowledge required for effective program implementation.
Additional Issues Identified
Beyond the major deficiencies in infection prevention leadership, surveyors documented related concerns about the facility's infection control practices. The infection preventionist explained that while daily meetings included discussions of new or suspected infections, this information was not documented or incorporated into room mapping to track potential disease spread.
The facility's policy titled Antibiotic Stewardship, revised in January 2024, stated that the facility would track antibiotic use daily and monitor for all adverse reactions and outcomes related to antibiotic therapy. However, the inspection found no evidence of this daily tracking occurring during July 2024.
The lack of infection surveillance extended beyond just antibiotic-associated infections. The infection preventionist confirmed to surveyors that infections not being treated with antibiotics were not tracked or included in facility mapping, creating significant gaps in the facility's understanding of overall infection patterns among residents.
These systematic deficiencies in infection prevention oversight create risks that extend throughout the entire resident population. Nursing home residents are particularly vulnerable to infections due to advanced age, underlying medical conditions, and close living quarters that can facilitate disease transmission. Effective infection control programs serve as the primary defense against preventable illness and complications in these settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland Manor of Elko from 2024-07-18 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.