Failure to Designate Qualified Infection Preventionist for Infection Control Program
Penalty
Summary
The facility failed to designate a qualified individual as the Infection Preventionist (IP) responsible for overseeing the Infection Prevention and Control Program (IPCP). Review of facility documents revealed that the infection control tracking logs and related documentation were incomplete for several months, with missing information such as onset date, infection site, diagnosis, lab results, organism, antibiotics, isolation status, healthcare-associated infection status, and resolution date for multiple residents. The infection control binder also showed incomplete tracking logs, McGeer's criteria, mapping, and monthly reports from May onward. Interviews with the Interim Director of Nursing and the Regional Director of Clinical Services confirmed that the facility had not filled the IP position after the former Assistant Director of Nursing left in April, resulting in several staff members overseeing the program without clear designation or consistent specialized training. Certification records provided did not cover the period from May through August, indicating a gap in qualified oversight. Facility policies required the IP to have specific training and responsibilities, but no evidence was provided that these requirements were met during the identified period.