Failure to Employ Qualified Infection Preventionist
Penalty
Summary
The facility failed to employ a qualified individual to serve as the Infection Preventionist (IP) responsible for the infection prevention and control program. According to document reviews and staff interviews, the designated IP, who is also the MDS Coordinator, had not completed the required specialized training in infection prevention and control, having only started the modules in April. The Director of Nursing (DON) was also undergoing the same training, and both relied on a corporate nurse for assistance, who was not regularly present at the facility. The facility's policy required the IP to be adequately qualified and to have completed accredited continuing education, which had not occurred at the time of the survey. Further review revealed that the antibiotic stewardship program, which falls under the IP's responsibilities, was not up to date, as evidenced by an incomplete binder for the current year. Staff interviews confirmed uncertainty regarding the IP's prior training and the lack of completion of required documentation. Additionally, the facility was unable to provide updated policies from the new ownership when requested by surveyors, indicating a lack of clear guidance and oversight for the infection prevention and control program.