Inadequate Dedication of Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) was dedicated solely to the Infection Prevention and Control Program (IPCP) as required by regulations. The IP, who was also acting in another role, indicated that she spent only an hour to an hour and a half each day on her IP duties, with the majority of her time spent on other responsibilities. This was contrary to the requirement that facilities with 100 or more beds must hire a full-time employee in the infection prevention role with no other responsibilities. The surveyor's interviews revealed that the IP position was part-time and temporary, and there was uncertainty about whether the allocated hours were sufficient for the role. Despite the IP's assurance that infection control measures were up to date, the facility did not comply with the directive to have a full-time IP dedicated solely to infection prevention and control, as evidenced by the job description and position action form provided by the facility.
Plan Of Correction
Element 1 Upon identification of the issue regarding the employee covering Infection Prevention (IP) and Unit Manager duties, the employee's role and responsibilities were reviewed. A formal assessment was completed to ensure the employee was properly supported in these dual roles and was provided with the necessary training and resources. The facility transitioned a current staff nurse to the dedicated Unit Manager position effective 1/27/2025, and the employee covering these roles was transitioned back to their original full-time duties as the dedicated Infection Preventionist with no other responsibilities. Element 2 All residents have the potential to be affected. Element 3 The facility has established a more structured planning protocol to ensure continuity of care and leadership in all key roles, including Infection Preventionist and Unit Manager. A permanent, qualified Infection Preventionist and Unit Manager have been appointed immediately to ensure clear leadership and responsibility in these areas. Element 4 The facilities leadership (Administrator and Director of Nursing) will meet with the Infection Preventionist and Unit Manager monthly for continued support in their roles and will be reassessed to ensure they are meeting the requirements of their positions.