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 Lacked Required Certification Documentation: The facility failed to ensure the designated IP was certified and had completed the required specialized infection prevention training. An Administrative Nurse was unable to provide evidence of the IP's certification and stated the IP had taken over the role in December 2025, had earned certification at another facility, and did not have a copy of it. The facility policy required the IP to have specialized certification before assuming the role and to provide documentation of completion.
Unqualified Infection Preventionist Assigned: The facility failed to ensure a qualified IP was designated to oversee the infection prevention and control program for 115 residents. The IP stated she was still in the IP course and had not completed it, while the job description and facility policy required specialized IPC training and relevant qualifications before assuming the role. The IP reported relying on a notebook from the previous IP, the DON, and corporate resources, and the DON and Administrator acknowledged the IP was still working on certification.
Failure to assign an infection preventionist. The facility’s infection preventionist resigned, and the administrator and DON stated that no one had been assigned or had accepted the duties of the position. The role remained unfilled, and no staff member had taken on the infection preventionist responsibilities.
Failure to Designate an Infection Preventionist: The facility did not have a designated IP responsible for the IPCP after the IP resigned, and the position remained vacant while the DSD only handled NHSN reporting for Covid, Flu, and RSV. The DON and ADM both confirmed there was no IP providing oversight of infection control, antibiotic stewardship, surveillance, or vaccination tracking, despite facility policy and the ICN job description outlining those responsibilities.
The DON/IP did not maintain oversight of the IC program for employee illness surveillance. Resident illness was tracked, but employee surveillance was not included in the IC documentation, and call-in records showed multiple employees with GI symptoms returning to work without documentation of symptom resolution or confirmation that return-to-work criteria were followed. The staffing coordinator and department managers handled call-ins, while the DON/IP stated she did not track employee illness and did not keep documentation of morning meetings.
Failure to designate a qualified IP for the IPCP. An interim nurse said she could not locate her IP certificate, had not really completed much of the IP duties, and was only enrolled in IP courses. Another admin staff member thought the interim nurse had a current IP certificate and expected the facility to have a designated certified IP. The facility did not provide an IP policy.
Infection Preventionist Lacked Required Certification Documentation
Penalty
Summary
The facility failed to ensure the staff person designated as the Infection Preventionist (IP), who was responsible for the Infection Prevention and Control Program (IPCP), was certified and had completed the required specialized training in infection prevention and control. During record review on 08/04/2026 at 08:45 AM, Administrative Nurse D was unable to provide evidence of certification for the facility's IP. Later that morning, Administrative Nurse D stated she had taken over the IP position in December 2025, had obtained her IP certification at another facility, and did not have a copy of it, adding that she had been unable to obtain it. The facility policy stated the designated IP must have obtained specialized IP certification beyond initial professional training or education prior to assuming the role and must provide evidence of training through a certificate of completion or equivalent documentation.
Unqualified Infection Preventionist Assigned
Penalty
Summary
The facility failed to ensure a qualified Infection Preventionist (IP) was designated to oversee implementation of the infection prevention and control program for 115 census residents. The facility policy titled, Infection Preventionist, stated the facility would designate a qualified individual as IP and that the IP must have obtained specialized IPC training beyond initial professional training or education prior to assuming the role, with evidence of training through a certificate of completion or equivalent documentation. The job description for Infection Preventionist, signed by the IP, required relevant licensure or certification and education, training, experience, or certification in infection control and prevention, including completed specialized training in infection prevention and control through accredited continuing education. During interviews, the IP stated she was still in the IP course and had not completed it, was in Module 12, and had been in the position since April 2026. She stated she had been using a notebook from the previous IP, the DON as a resource, and two corporate staff resources were available. The DON stated there were two nurse consultants with IP certification and that she was aware of the IP training and education requirements. The Administrator stated the IP was working on her certification and had additional resources.
Failure to Assign an Infection Preventionist
Penalty
Summary
The facility failed to ensure a qualified employee was assigned to perform the duties of infection preventionist for the infection prevention and control program. The policy titled Infection Preventionist stated that the infection preventionist is responsible for coordinating the implementation and updating of the facility’s infection prevention and control policies and procedures. Record review showed the infection preventionist was terminated, with the last day worked on 07/20/26. The administrator stated on 07/22/26 that the infection preventionist had resigned that morning and that no one had been assigned to perform those duties at that time. The DON later stated on 07/28/26 that the former infection preventionist had abruptly resigned and that no one had accepted the duties of the position. The administrator also stated on 07/28/26 that the position had not been filled and no one had taken on the duties of infection preventionist.
Failure to Designate an Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) responsible for the Infection Prevention and Control Program (IPCP) for 62 residents and staff after the IP resigned in 6/2026. During interview, the Director of Staff Development stated she had been the IP until 6/2026 after the previous DSD resigned in 4/2026, and that the IP position had been vacant since 6/2026 with no one filling it. She stated the only infection control activity she was currently working on was reporting to NHSN for Covid, Flu, and RSV, and that no one was providing oversight of the IPCP. The DON stated there was no IP to provide oversight of the IPCP at the facility and that an IP was needed full time to check residents with G-tubes for infection, observe infection control practice, oversee the antibiotic stewardship program, and keep a line list of staff and residents' vaccinations. The Administrator stated there was not an IP since 6/2026, that the position was vacant, and that an interview for a full-time IP had been conducted on 7/15/26 with an offer extended and a response pending. Facility policy stated infection control policies and practices were intended to maintain a safe, sanitary, comfortable environment and help prevent and manage transmission of diseases and infections, and the Infection Control Nurse job description described responsibilities including resident assessments, surveillance rounds, review of culture reports, outbreak investigation, and coordination with nursing and laboratory personnel.
Infection Preventionist Lacked Oversight of Employee Illness Surveillance
Penalty
Summary
The facility failed to ensure the infection preventionist, who was also the director of nursing, had appropriate oversight of the infection control program, including employee surveillance for all employees. Review of the infection control surveillance documents showed resident illness surveillance was being tracked, but employee surveillance was not included in the documentation. During interview, the DON/infection preventionist stated she had nothing to do with tracking or managing employee illness and that employee illness was tracked by the human resources/scheduling coordinator. She also stated employee call-ins were discussed in morning meetings, but she did not maintain documentation of those meetings. Review of staff call-in forms showed multiple employees reported gastrointestinal symptoms and returned to work without documentation showing symptom resolution or that infection control return-to-work criteria had been followed. A nursing assistant reported diarrhea, another nursing assistant reported nausea, a cook reported vomiting and returned to dietary work the next day, and a dietary aide reported nausea and returned the next day. The staffing coordinator stated call-in forms were kept in her scheduling binder and that she primarily handled nursing staff, while department managers handled their own staff call-ins for other departments. The dietary manager stated he had followed the posted policy requiring employees to wait 24 hours after their last symptom before returning to work, and he identified that one cook returned before that time frame. The Infection Preventionist job description and the facility's infection prevention and control policy identified the IP as responsible for oversight of infection surveillance, including monitoring employee infections and coordinating the program.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) who had completed specialized training in infection prevention and control to be responsible for the Infection Prevention and Control Program (IPCP). During interview, Administrative Nurse E, the interim nurse, stated she could not locate her IP certificate, said that when she accepted the interim position an IP certification was not mentioned, and reported that she had not really completed much of the IP duties at the facility. She also stated she was enrolled in courses for IP at the time. Later, she produced the antibiotic/infection control log binder. Record review showed a Completion for Nursing Home Infection Preventionist Training Course for Administrative Staff A, who stated she thought Administrative Nurse E had a current IP certificate and expected the facility to have a designated certified IP employed there. The facility did not provide a policy for an Infection Preventionist.
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