Lack of Designated and Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) responsible for the Infection Prevention and Control Program (IPCP), as required by its own policy and regulatory standards. Record review and staff interviews revealed that the Director of Nurses (DON) was identified as the current IP, but had not completed the necessary infection prevention and control training. The Assistant Director of Nursing (ADON) was also still in training for the IP position, and neither had obtained specialized infection control training prior to assuming the role. The facility's policy requires the IP to be qualified by education, training, experience, or certification, and to have completed specialized IPC training, which was not met in this case. Additionally, the facility assessment did not include the IP role or specify the required hours for the position, despite policy requirements that the IP's time and involvement be determined by the facility assessment. The assessment only documented that the IPCP was maintained by the DON or designee, without identifying a specific IP role. Interviews with the Nursing Home Administrator (NHA), DON, and ADON confirmed the lack of a designated, qualified IP and the absence of required training, affecting all 30 residents in the facility.