Infection Preventionist Role Not Designated
Penalty
Summary
The facility was cited for not designating an individual as the Infection Preventionist responsible for the facility's Infection Prevention Control Practices. Instead, the Director of Nursing (DON) had been performing a dual role as both the Infection Preventionist and Nurse Educator since May 10, 2023. This dual role was due to staffing issues, as stated by the DON during an entrance interview. The facility's policy and procedure on Infection Prevention and Control, revised in 2024, indicated that inquiries concerning infection control should be referred to the Infection Preventionist or DON. However, the facility failed to have a specified individual solely responsible for infection prevention, which is a requirement under the regulations. During the survey, it was revealed that the Administrator was unaware that the Infection Control Preventionist should not have a dual role with the DON. The review of key personnel documentation from 2023 confirmed that the DON was listed as the designated Infection Preventionist. The deficiency was identified under the 10 New York Code of Rules and Regulations 483.80 (b) (1)-(4) (c), which mandates that the Infection Preventionist should have a specific role without dual responsibilities. This oversight in staffing and role designation led to the citation during the recertification survey.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Corrective Action for those identified: No residents were affected by the deficient practice. The Infection Preventionist role was reassigned to the ADON, who achieved certification on 2/22/25. Identification of other residents and corrective action: No residents were affected by the deficient practice. Measures and Systemic Changes: The Infection Control Committee policy was reviewed and revised to correctly identify the Infection Preventionist. The ADON job description was revised to include the Infection Preventionist responsibilities on 3/6/25. Monitoring: An annual audit will be conducted to ensure that the IP continues to meet the requirements as set forth in F882. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: Director of Nursing by 3/31/25