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F0945
E

Failure to Provide Required Infection Control and COVID-19 Training

Barrigada, GU Survey Completed on 08-22-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide mandatory in-service training on infection prevention and control, specifically regarding current COVID-19 vaccination requirements and Enhanced Barrier Precaution (EBP) practices, to its staff. Interviews with multiple staff members, including RNs, LPNs, and CNAs, revealed that they had not received recent or specific training on these topics. The Infection Control Officer (ICO) confirmed that no documented infection control education or in-service training had been provided from 2023 to the present, with the last recorded session occurring in July 2023. Staff reported learning about EBP informally from a previous surveyor rather than through formal training, and there was no evidence of education on COVID-19 vaccination requirements or related benefits, risks, and side effects. Review of training records for several staff members showed no completed training for EBP or COVID-19 vaccination requirements. The facility's own infection control policy requires in-service education for all employees, with emphasis on hand hygiene, PPE use, and infection control practices, but this was not followed. The ICO stated that COVID-19 vaccination education was only provided to those who agreed to receive the vaccine, and that the hospital's web-based training did not cover infection control topics relevant to the current requirements. This lack of documented and comprehensive training was confirmed through both staff interviews and record reviews.

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