Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to have a designated Infection Preventionist (IP) responsible for the Infection Prevention and Control Program, as required by facility policy and federal regulations. During interviews, the Administrator and Director of Nursing (DON) confirmed that the facility did not have a current IP after the previous IP resigned following a personal loss. The Administrator initially believed the MDS nurse had assumed the role, but later clarified that the Assistant Director of Nursing (ADON) and the DON were overseeing infection control duties. Documentation showed the ADON was registered for infection control training, and the Staff Development Coordinator (SDC) was also signed up for future training to serve as a backup. The facility was temporarily consulting with the county health department's Infection Control Nurse as needed. Review of facility policies indicated that the IP is responsible for surveillance, investigation, documentation, and reporting of infections, as well as implementing measures to prevent infections among residents and staff. Despite these requirements, the facility did not have a formally designated IP at the time of the survey, and infection control responsibilities were being shared among existing staff. Infection tracking logs for the relevant period did not identify concerns with infection monitoring, and infection data was reviewed during QAPI meetings. However, the absence of a designated IP was confirmed by both the Administrator and DON, and the facility's inability to promptly provide infection control information to surveyors further highlighted the deficiency.