Infection Control Training Deficiency
Penalty
Summary
The facility failed to provide mandatory infection control training as part of its infection prevention and control program for one of nine staff members, specifically Registered Nurse Employee E13. The review of facility personnel in-service training records and staff interviews revealed that Employee E13, who was hired on October 6, 2022, did not receive documented infection control in-service education between October 6, 2023, and October 6, 2024. During an interview on January 24, 2025, the Nursing Home Administrator confirmed the lack of infection control training for eight of nine staff members, indicating a broader issue with compliance in the facility's training program.
Plan Of Correction
1. The facility will ensure employees receive infection control training on a yearly basis. 2. A full house employee file audit will be conducted to identify the training needs of each employee to ensure ongoing yearly training. 3. The Human Resources Director or designee will ensure that each employee of the facility receives infection control training on a yearly basis by reviewing their training courses prior to their performance appraisal due date. If the training has been inadvertently missed, the employee will be trained on the missed course prior to the performance appraisal being completed. 4. The Administrator or designee will review 5 employee files due for performance review each month to ensure yearly training is completed weekly x4 weeks. The QAPI committee will determine the need for further audits.