Failure to Designate Qualified Infection Preventionist for IPCP Oversight
Penalty
Summary
The facility failed to ensure that its Infection Prevention and Control Program (IPCP) was overseen by a qualified individual with the necessary knowledge, skills, and dedicated time to perform the required duties for eleven out of twelve months. According to facility policy, the infection preventionist is responsible for conducting surveillance of infections, providing education based on findings, and overseeing the antibiotic stewardship program. However, interviews revealed that the designated infection preventionist, an LPN, was primarily assigned to floor duties and the restorative program during this period, leaving insufficient time to fulfill IPCP responsibilities. The infection preventionist admitted to not mapping infections and being unable to track the spread of infections within the building. Additionally, the infection preventionist was unable to answer questions regarding the antibiotic stewardship program, deferring to the Director of Nursing for information. The Director of Nursing confirmed that the facility did not have an individual adequately assessing, developing, implementing, monitoring, and managing the IPCP for the majority of the year. The lack of infection mapping and oversight of the antibiotic stewardship program were specifically noted as deficiencies. The findings were based on a review of facility policies and staff interviews, and the cited regulations included requirements for management, personnel records, and nursing services.