Insufficient Infection Preventionist Coverage for Infection Control Program
Penalty
Summary
The deficiency involves the facility’s failure to employ and schedule a qualified Infection Preventionist Nurse (IPN) at least part time, as required by state expectations and as outlined in the facility’s own Facility Assessment Tool and infection prevention and control policy. Review of the LVN schedules and IPN timecards for November and December 2025 and January 2026 showed the IPN was only scheduled and actually worked a limited number of days and hours each month, far below the 40 hours per week of IPN coverage that the DON and administrator stated were required. In November 2025, the IPN worked three 8‑hour days; in December 2025, three 8‑hour days; and in January 2026 through 1/27/2026, two 8‑hour days. The facility’s policy stated that the designated infection preventionist is responsible for oversight of the infection prevention and control program, including consultation on infectious diseases, room placement, isolation precautions, exposures, surveillance, and epidemiological investigations. Staff interviews confirmed that the IPN was not present on a full‑time basis and did not provide consistent infection prevention in‑services and trainings. A CNA reported that the IPN did not have a full‑time schedule and did not consistently conduct infection prevention education. The MDS coordinator stated that resident isolation protocols and guidelines were set by the IPN and that the IPN came to the facility only once or twice a week for a few hours. The DON and administrator both acknowledged awareness of the 40‑hour IPN coverage requirement but stated that, because the building was smaller, the IPN only came a few times a week. In a telephone interview, the IPN stated she considered herself full time, working two to three 8‑hour shifts per week, and was aware that skilled nursing facilities are required to have 40 hours of IPN coverage. The Facility Assessment Tool identified infection prevention and control as a needed type of care for the resident population and specified that infection control and prevention staff were required, as well as systems for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for residents, staff, volunteers, visitors, and contracted providers.
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