Failure to Designate and Allocate Time for Infection Preventionist
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was designated to manage the Infection Prevention and Control Program at least part-time, as required. Review of facility documentation and interviews revealed that the assigned RN, who was responsible for the infection control program, was also performing multiple other roles, including wound care, staff development, and RN supervision during the day shift. The RN and the Director of Nursing Services (DNS) both confirmed that there was no specific or quantifiable amount of time set aside for infection prevention duties, and they worked on the program only when time allowed. Punch records and staffing assignments showed that the RN was scheduled as the RN supervisor for the majority of the month, with no additional hours dedicated to infection prevention activities outside of this role. During an influenza outbreak, the facility's surveillance tracking log did not identify a resident with symptoms consistent with influenza as requiring testing, indicating a lapse in outbreak management. The facility's job description for the Infection Control Coordinator specified that the primary responsibility was to direct the infection control program, but the actual practice did not align with this requirement. The facility assessment also indicated that there should be one designated Infection Preventionist, but the evidence showed that this role was not being fulfilled as intended.