Infection Preventionist Lacked Certification and Incomplete Infection Control Documentation
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP), a registered nurse, obtained the required Infection Prevention Certificate prior to assuming the role. The IP was hired and began working in the dual role of Infection Preventionist and Wound Care Nurse without prior formal infection prevention training, only receiving on-the-job training from the previous IP for two weeks. The certificate was obtained nearly two months after starting in the position. Additionally, the previous IP ceased oversight and involvement in infection prevention activities after transitioning to a floor nurse role. The facility also failed to maintain accurate and complete infection control logs and surveillance maps. Several infections, including Clostridium Difficile and Candida Auris, were not documented in the logs or maps for multiple months, and the December infection control log was not available for review until the end of the month, with no surveillance map provided. Interviews with staff and the infectious disease physician confirmed ongoing issues with infection control documentation and oversight, with the physician noting a severe problem related to high rates of severe opportunistic infections.