Failure to Designate Qualified Infection Preventionist During COVID-19 Outbreak
Penalty
Summary
The facility failed to designate a qualified infection preventionist nurse (IPN) to oversee the Infection Prevention and Control program during a period when a COVID-19 outbreak was occurring. According to the facility's records, the last day the former IPN worked was 5/20/2025, and as of 5/21/2025, there was no designated IPN present. The Director of Nursing (DON) reported covering the IPN role despite not having IPN certification. The COVID-19 outbreak had been declared on 5/12/2025, and at least three COVID-19 positive cases were identified among residents and/or staff within a seven-day period. Interviews with the DON confirmed that the facility did not have a certified IPN during the outbreak, and the DON acknowledged the need for a certified IPN to monitor and prevent infections. Review of the facility's job description for the Infection Control Coordinator (ICC), also known as the IPN, indicated that this role is responsible for promoting and maintaining infection control guidelines and ensuring all infection control documentation is maintained according to federal and state requirements. The absence of a designated and qualified IPN during an active outbreak constituted a failure to implement the facility's Infection Prevention and Control program as required.