Failure to Designate Qualified Infection Preventionist and Manage Respiratory Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to designate and employ a qualified Infection Preventionist (IP) to develop, implement, and monitor the infection prevention and control program, including during an active outbreak of COVID-19, influenza, and RSV. The facility identified a Regional Nurse as the IP, reportedly working 20 hours per week, but the Regional Nurse’s job description focused on overall facility operations and only generally referenced following established infection control procedures. The facility lacked a qualified back-up IP, and the designated IP was not present in the facility and unavailable for interview during multiple days of the survey while the outbreak was ongoing. During the IP’s absence, the DON and ADON reported they were responsible for managing the infection control program and the current outbreak, but both confirmed they were not trained as IPs, could not interpret the IP’s information, and could not act on her behalf. They also stated they did not have access to the EMR Infection Tracking Program and would not be able to read or understand the information even if they obtained access. The surveyors requested outbreak-related documentation multiple times, including staff and resident line listings, an outbreak management plan, and evidence of respiratory symptom tracking for non-infected residents, but the facility could not provide an outbreak management plan or documentation showing tracking of non-infected residents. Infection control documentation from the facility’s PCC Infection Control Management System showed that outbreak status had not been evaluated, tracked, or updated for several days, and contact tracking documentation had not been updated since the date it was initiated. The deficiency also included specific resident-level findings and infection control lapses. One resident with a history of stroke developed respiratory symptoms and later tested positive for both influenza and RSV, another resident with Parkinson’s disease developed respiratory symptoms and tested positive for influenza, and a third resident with atrial fibrillation and a recent pubic bone fracture developed respiratory symptoms and tested positive for COVID-19. Surveyors observed that required isolation/PPE signage was not posted outside the rooms of residents with RSV and/or influenza. A visitor entered and exited one such resident’s room multiple times without performing hand hygiene or donning PPE, and housekeeping staff reported they were unaware of the residents’ infectious status or required PPE and confirmed there were no signs at the doorways directing them on precautions.
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