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F0726
E

Failure to Provide Ongoing Infection Control Training During Outbreaks

Madera, California Survey Completed on 04-15-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the Infection Preventionist (IP) possessed and demonstrated the necessary competencies and skills to provide ongoing in-service training and education to staff during outbreaks of Norovirus and Influenza. The IP did not conduct refresher or make-up in-service sessions after the initial training, despite confirmed cases and an active outbreak. Interviews with dietary staff, nurses, and certified nursing assistants revealed that many did not recall attending infection control in-services provided by the IP after the outbreak began, and there was no evidence of reminders or posted schedules for such training. The IP acknowledged that in-service training on Norovirus was provided 15 days before the first confirmed case, but no additional sessions were held after the outbreak started. Attendance at subsequent in-services on Influenza and related precautions was low, and the IP did not communicate this to facility leadership or attempt to ensure all staff received the necessary education. The Director of Staff Development (DSD) and Director of Nursing (DON) both stated that they were not informed of the low attendance and did not provide or coordinate additional training, with the DSD indicating she would have assisted if asked. Facility policies required ongoing education and competency evaluation for staff during outbreaks, but these were not followed. The lack of comprehensive and timely in-service training for all staff, especially those providing direct care, resulted in staff being inadequately prepared to manage and prevent the spread of infection among residents, staff, and visitors during the Norovirus and Influenza outbreaks.

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