Failure to Designate Qualified Infection Preventionist and Maintain Infection Control Program
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was designated and responsible for the infection prevention and control program. The previous IP, who was the Director of Nursing, left the facility on April 4, 2025, and the duties were assigned to the MDS Nurse, who had not completed specialized training in infection prevention and control. The Administrator confirmed that there was no staff member onsite who had completed the required specialized training in infection control at the time of the survey. Additionally, infection control surveillance tracking provided for January, February, and March 2025 was found to be incomplete, and there was no tracking available for April 2025. The most recent infection control in-service training for staff was conducted in December 2024, with no further training provided in 2025. The facility's policy requires the IP to lead surveillance activities, maintain documentation, and report findings, but these responsibilities were not being fulfilled due to the lack of a qualified IP and incomplete surveillance documentation.