Lack of Qualified Infection Preventionist for Infection Control Program
Penalty
Summary
The facility failed to designate a qualified individual as the Infection Preventionist (IP) responsible for the infection prevention and control program, as required by policy and regulation. According to the facility's policy, the IP is responsible for ongoing surveillance of healthcare-associated infections, determining the need for laboratory tests and special precautions, and gathering and interpreting surveillance data. During the survey, it was found that the Director of Nursing (DON) was serving as the IP but had not completed any specialized infection control training and was not certified. The previous IP had resigned a month prior, and since then, the DON, with assistance from nursing leadership, had been overseeing the infection control and antibiotic stewardship program without the required qualifications. Interviews with facility leadership confirmed that there was no certified IP in place at the time of the survey. The Administrator acknowledged the absence of a certified IP and stated that the DON was managing the program to the best of their ability. The Regional DON also confirmed that there was no corporate IP available and that two newly hired Assistant Directors of Nursing would be trained and certified in the future. No specific residents or patient conditions were mentioned in relation to this deficiency.