Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified and certified Infection Preventionist (IP) to be responsible for the infection prevention and control program. Documentation provided by the Administrator indicated that the Director of Nursing (DON) was assigned as the IP nurse. However, the DON was unable to demonstrate that she dedicated at least 20 hours per week to infection prevention duties, as she was also working full time as the DON. Additionally, the DON confirmed that she was responsible for infection prevention quality and assurance but could not show evidence of meeting the required time commitment for the IP role. Further interviews revealed that an RN was responsible for infection tracking and monitoring but had not received certification in Infection Prevention and Control. The Corporate Administrator acknowledged awareness of the requirement for a staff member, other than the DON, to be devoted to the IP nurse role. Review of the job descriptions confirmed that the IP position required specialized infection prevention and control training beyond initial professional education, which neither the DON nor the RN possessed at the time of the survey.