Inadequate Infection Control Program Oversight and Documentation
Penalty
Summary
The facility failed to ensure that the designated infection preventionist (IP) was appropriately trained and that the infection control (IC) program was properly overseen by management. The IP, hired in April 2025, was still in training and had not yet started certification classes. During this period, the facility did not maintain adequate daily cumulative infection control surveillance activities, nor did it ensure complete documentation of staff illness incidents, findings, and any corrective actions. Review of staff illness forms and surveillance logs revealed missing information such as last day worked, symptom resolution dates, and return-to-work dates for multiple staff members, including the IP. Required details about symptoms and exposure were also inconsistently recorded. Interviews with the IP, a certified RN, and the DON revealed a lack of clear communication and oversight regarding the infection control program. The certified RN, although available to assist, was not officially providing oversight to the new IP and was unaware of any formal delegation of this responsibility. The DON acknowledged that expectations for oversight were not clearly communicated and that there were concerns about incomplete staff illness logs. The facility's job description for the IP required proficiency in surveillance and collaboration with employee health, but these functions were not being fully met during the period in question.