Failure to Designate a Qualified Infection Preventionist Led to CPO Outbreak
Summary
Facility 1 failed to ensure that a qualified and designated Infection Preventionist (IP) was responsible for adequately assessing, developing, implementing, monitoring, and managing the facility's Infection Prevention and Control Program (IPCP). Instead, one IP was assigned to cover both Facility 1 and Facility 2, which are separate entities operating under different licenses. The IP reported that she was required to work across both facilities, averaging 45 hours per week, and stated that each facility required a full-time IP to effectively manage infection control. Despite the IP's instructions to prevent staff from working in both facilities during an outbreak, the scheduling coordinator continued to assign direct care staff to work double shifts in both locations, contributing to the spread of infection. A review of facility records and laboratory reports revealed an increase in Carbapenemase-Resistant Organism (CPO) infections in Facility 1, including cases of Klebsiella Pneumoniae Carbapenemase (KPC), New Delhi Metallo-β-lactamase (NDM), and Carbapenem-Resistant Pseudomonas aeruginosa (CRPA). The affected residents had complex medical histories, including conditions such as encephalopathy, acute respiratory failure, tracheostomy status, ventilator dependence, traumatic brain injury, spastic quadriplegic cerebral palsy, and myotonic muscular dystrophy. The cross-contamination and transmission of these infections to non-infected residents were linked to the failure to implement effective infection control measures and the sharing of staff between the two facilities during an outbreak. Interviews with the IP and the facility administrator confirmed that there was only one shared IP for both facilities, and the administrator was unaware of the regulatory requirement for each facility to have its own IP. The facility's policy stated that the IP should be employed on-site and scheduled with enough time to properly manage the IPCP, but this was not followed. The lack of a dedicated IP for Facility 1 and the continued sharing of staff between facilities during an outbreak directly contributed to the increase and transmission of multi-drug resistant organism infections.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Infection Preventionist Failed to Track and Trend Recurrent UTIs: The designated IP did not complete infection surveillance, track or trend infection data, or analyze recurring UTI patterns. The IP stated she mainly reviewed antibiotic orders and entered them into the monthly log, was unsure of infection criteria, and was behind on documentation. Logs showed multiple recurrent UTIs, including repeated E. coli cultures, but there was no documentation of analysis, source identification, or staff education related to the recurring infections.
The facility failed to designate a qualified infection preventionist to oversee the infection control program. The infection preventionist policy required the role to be filled by someone qualified through education, training, experience, and/or certification, but the ADON/Infection Preventionist stated she had not completed the required nursing home infection preventionist training course, and facility records confirmed the course was not completed. The NHA confirmed the facility had not designated a qualified individual responsible for infection prevention and control.
The facility failed to have a designated IP who had completed the required specialized infection prevention and control training for 2 of 2 nurses reviewed. The DON and Regional Compliance Nurse said the DON and ADONs were handling infection control protocols and surveillance, but an ADON stated she was not the IP and did not track infections. The previous DON had been the designated IP, and the DON and ADON LVN K had started the required training but had not completed it; the facility policy stated the IP would monitor the infection control program and provide education and training.
Failure to designate a qualified IP was cited after the facility moved the Infection Control Nurse into the DON role when the DON resigned and promoted a nursing supervisor to Assistant DON and Infection Control, even though that person was not yet certified and had only started training. The facility’s policy and job description required the IP to conduct surveillance for HAIs and other significant infections and to manage the infection prevention program under the DON.
Infection Preventionist Lacked Dedicated Time for Infection Surveillance: The facility failed to ensure the IP had dedicated time to manage the infection prevention and antibiotic stewardship program. The RN/IP was also serving as ADON and wound nurse and was working three 12-hour floor shifts because of staffing shortages, leaving the infection control log incomplete and without tracking or trending. Two residents with UTIs had positive urine studies and one received Cipro despite resistance, but neither infection was entered on the infection control log.
The facility failed to designate a qualified Infection Preventionist responsible for the infection prevention and control program. The DON stated the IP position was vacant and that she and the ADON were sharing the duties, but she could not provide documentation showing that either had completed the required specialized training. She also believed the SDC may have completed SPICE, but documentation could not be obtained.
Infection Preventionist Failed to Track and Trend Recurrent UTIs
Penalty
Summary
The facility failed to ensure the designated Infection Preventionist (IP) implemented and monitored the Infection Prevention and Control Program by not conducting infection surveillance, tracking and trending infections, analyzing infection data, or identifying infection control concerns. The IP job description stated the IP was responsible for development, implementation, oversight, and evaluation of the program, but the IP reported she only reviewed physician orders for antibiotics and entered information into the monthly infection tracking log. She stated she did not review resident symptoms when monitoring infections, was unsure what infection criteria were used to identify infections, and had not completed the May 2026 infection control log, stating she was usually about one month behind in documentation. Record review of the urinary tracking infection logs from February 2026 through April 2026 identified 54 UTI episodes, excluding residents admitted with infections and duplicate entries for the same active infection, with multiple residents experiencing recurrent UTIs. The logs included resident names, organisms identified, antibiotic treatment, treatment completion dates, and follow-up culture results, but there was no documentation that the infections were analyzed for trends, contributing factors, recurring organisms, or opportunities for intervention. The logs also showed a recurring pattern of E. coli in urine cultures, yet there was no evidence of surveillance to identify contributing factors, determine the source, or implement corrective interventions. The IP confirmed she had not tracked or trended infections, evaluated recurring infection patterns, analyzed infection data, or provided staff education regarding perineal care, catheter care, hydration, or other interventions related to the recurring infections.
Unqualified Infection Preventionist Assigned
Penalty
Summary
The facility failed to designate a qualified individual responsible for implementing and overseeing the infection control program. The facility’s infection preventionist policy, dated February 6, 2026, stated that the infection preventionist must be qualified by education, training, experience and/or certification and have sufficient knowledge to perform the role. During an interview on May 28, 2026, the Assistant DON/Infection Preventionist stated that she did not complete the required nursing home infection preventionist training course. Facility-provided certification records also showed that she had not completed the nursing home infection preventionist training course required to fulfill the role. The NHA later confirmed that the facility failed to designate a qualified individual responsible for implementing programs and activities to prevent and control infections.
Infection Preventionist Training Not Completed
Penalty
Summary
The facility failed to have a designated Infection Preventionist who had completed the required specialized training in infection prevention and control for 2 of 2 nurses reviewed as designated Infection Preventionists. During an interview on 05/22/26, the DON and Regional Compliance Nurse M stated that the DON and ADONs were implementing and monitoring infection control protocols and surveillance activities. The state surveyor was provided a training certificate showing completion of the Nursing Home Infection Preventionist Training Course for ADON RN L, dated 03/20/26. During a later interview, ADON RN L stated that she was not the Infection Control Preventionist, did not assist with the Infection Control Program, and did not track infections. HR Coordinator N stated that the previous DON’s last day of work was 12/09/25. Regional Compliance Nurse M and the DON stated that the previous DON had been designated as the Infection Control Preventionist, and that the DON, ADON LVN K, and the Administrator were in the process of completing the required Infection Control Preventionist training. The DON stated that she and ADON LVN K had started the training and it had not been completed as of 05/22/26. The facility’s Infection Control Plan stated that the IP would monitor the infection control program, provide education and training, and complete CDC training along with the DON and Administrator.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections. A review of the facility policy on Surveillance for Infections dated 4/1/26 showed that the infection preventionist was expected to conduct ongoing surveillance for healthcare-associated infections and other epidemiologically significant infections that could affect resident outcomes and require transmission-based precautions or other preventive interventions. A review of the Infection Preventionist job description dated 4/1/26 showed that the role required completion of CDC Long Term Care Infection Preventionist training or another acceptable certification within 30 days of employment, and that the IP would report to the DON and manage the infection prevention program, including surveillance and an annual surveillance plan. During an interview, the NHA stated that the facility moved the Infection Control Nurse into the DON position after the DON resigned, and promoted a nursing supervisor to Assistant DON and Infection Control on 5/18/26, but that person was not yet certified and had only started training. The NHA confirmed that the facility failed to designate a qualified individual onsite responsible for infection prevention and control.
Infection Preventionist Lacked Dedicated Time for Infection Surveillance
Penalty
Summary
The facility failed to ensure the Infection Preventionist (IP) had dedicated time to carry out infection prevention and control duties and maintain a comprehensive infection control program. Review of the May 2026 infection control log showed no evidence of tracking or trending as of 05/13/26. During interview, the Scheduler confirmed RN/Infection Preventionist #117 had started working three 12-hour floor shifts on 04/12/26 after previously working five 8-hour shifts, and that she was also the ADON and Wound Nurse. RN #117 stated she had been working three 12-hour shifts on the floor for the prior three weeks because of a nursing shortage and had not yet started the May infection control log, although she reported there had been five or six infections in May and she was trying to work on the log during her free time. Review of the facility assessment dated 01/2026 showed no evidence identifying the IP or the hours required to maintain the infection control and antibiotic stewardship program, and the facility’s Infection Prevention and Control Program and Antibiotic Stewardship policy did not include designated time for the IP. Record review also showed Resident #48 was admitted with a UTI and had a final urinalysis on 04/20/26 showing greater than 100,000 CFU/ml of ESBL E. coli, but the infection was not entered on the 04/2026 infection control log. Resident #31 was admitted with acute kidney failure and urinary retention, had a urine culture on 05/02/26 growing 25-30,000 Proteus mirabilis resistant to Cipro, and received six doses of Cipro 500 mg for a UTI; this potential infection also was not logged on the 04/2026 or 05/2026 infection control logs. RN #117 confirmed both residents’ infections were not logged despite the IP’s responsibility for the infection control program.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist responsible for the Infection Prevention and Control Program. During an interview on 5/5/2026, the DON stated that the Infection Preventionist position was vacant and that she and the ADON were sharing the responsibilities. She said both had completed infection prevention programs out of state and that she would try to retrieve documentation. The DON could not recall the name of the infection prevention and control program she completed in Ohio, but said it was similar to the SPICE program offered in North Carolina. On 5/6/2026, the DON stated she had been unable to locate documentation for herself or the ADON, but believed the SDC had completed SPICE and would obtain that documentation. In a later interview the same day, the DON stated she was unable to obtain documentation showing that there was a qualified Infection Preventionist at the facility. The Administrator was not available for interview during the survey.
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