Lack of Qualified Infection Preventionist for Infection Control Program
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was responsible for the Infection Prevention and Control Program (IPCP). The Assistant Director of Nursing (ADON), who was previously responsible for overseeing the IPCP, had vacated the position three weeks prior to the survey. In the absence of the ADON, the Director of Nursing (DON) was designated by the Administrator to serve as the IP, in addition to her full-time responsibilities as DON. The job description for the ADON required maintaining Infection Preventionist Certification, and the role included oversight of the IPCP and the Antibiotic Stewardship Program. Upon review of the DON's qualifications, it was found that she had professional nursing training and an active RN license, but lacked current specialized training or certification as an Infection Preventionist. The only evidence of relevant training provided was participation in a Nursing Home Infection Preventionist Training Course over four years prior and a certificate for 2.5 continuing education units in Universal Infection Prevention and Control from the previous year. The DON confirmed she was not certified in Infection Prevention and Control from the Certification Board of Infection Control and Epidemiology (CBIC) and had not worked as an IP since completing the earlier educational activity.