Table 4.

Themes

Theme	Explanation	Exemplar Quotes
Residents’ Needs	Tension exists between the facility being the residents’ home and the need for effective infection prevention and control procedures.	“I had a dementia resident who was positive for C. diff. He was not heavily symptomatic. It wasn’t like he was walking in the hallway and creating a disaster, but the potential is there, and it was just redirecting him…let’s take him outside for some fresh air, let’s make sure he’s not going into the gym or into the dining room. If he’s walking in the hallway, it’s a little bit different, let’s redirect him back to his room.” IP site 2
Roles and Training	Many employees involved in infection control program had multiple other responsibilities and frequently lacked formal training in infection prevention and control.	“I do a lot…I do the employee health… Infection Control…unit audits…. a lot of chart work…audits for medical records…closed medical record files…speak at resident counsel and family counsel.” IP site 4 “I don’t have any official infection control licensure, I just learned by experience and from my peers…it’s become my baby.” IP site 2
Using Infection Data	Infection data were used to improve care despite variations in surveillance methods/definitions.	“At the end of the month, I get a map of the facility. And I go through and I highlight the certain rooms that have the infection. And pink would represent urinary, blue would represent respiratory and so on. So that way you could see any trends that are going. You don’t want to see a whole bunch of pink in one area because that shows you, ok, that might be hand-washing. So that’s how we really kind of determine if we need to in-service our staff or not, is through those maps.” IP site 7
External Resources	External resources were a source of information and support for some.	“We work hand-in-hand with the DOH …and the CDC. I am on their website. They send me updates of what’s going on…” IP site 1
Focus on Hand Hygiene	All infection prevention programs focused on hand hygiene. Monitoring staff compliance with hand hygiene policies was often informal.	“Well the most basic thing is hand-washing, the use of gloves, wash hands before and after the use of gloves. You do not use one glove from one resident to the other.” IP site 1

Note: IP = infection preventionist; DOH = Department of Health; CDC = Centers for Disease Control and Prevention