Failure to Designate Qualified Infection Preventionist and Complete Infection Surveillance
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) nurse, other than the Director of Nursing (DON), to oversee the infection prevention and antibiotic stewardship programs. Record review showed that antibiotic tracking and infection surveillance were not completed for a seven-month period. During an interview, the DON stated she began working at the facility in December 2024 and was solely responsible for infection tracking, TB testing, surveillance, and the antibiotic stewardship program. She acknowledged she was unaware that the DON could not serve as the IP nurse and that an additional nurse with infection preventionist training was required for the role. Facility documentation indicated that both a full-time DON and a full-time IP nurse were designated, but in practice, only the DON was fulfilling these responsibilities. Policies provided by the administrator outlined that the IP nurse or designated infection control personnel should conduct ongoing surveillance, gather and interpret infection data, and coordinate the infection prevention program. However, these duties were not being carried out as required, as evidenced by the lack of infection surveillance and antibiotic tracking during the specified period. This deficiency had the potential to affect all 38 residents in the facility.