Failure to Maintain a Designated, Trained Infection Preventionist
Penalty
Summary
The deficiency involves the facility’s failure to designate a qualified Infection Preventionist (IP) who worked at least part-time and had completed specialized infection prevention and control training during the months of December 2025, January 2026, and February 2026. Record review showed that the DON had completed Nursing Home Infection Preventionist Training with a certificate dated 01/14/2026, but she did not begin working on the floor in the facility until 02/05/2026 and was still in training at that time. The facility’s policy titled “Surveillance for Infections,” revised September 2017, stated that the IP would conduct ongoing surveillance for healthcare-associated infections and other significant infections, but there was no evidence this surveillance was being conducted during the period when the DON position was vacant and when the new DON had not yet started working in the building. During interviews, the ADON reported that she had previously performed IP tasks such as tracking infections before the prior DON was hired, and that the prior DON’s last day was December 12, 2025. She stated there was no IP appointed when the DON position was vacant and acknowledged she could not provide any records showing recent infection tracking in the facility. The AIT confirmed that both the previous and new DONs had completed the infection preventionist program and provided the new DON’s IP certificate dated 01/14/2026. The AIT also reported that another staff member had infection control-related training, but the certificate provided, dated 10/25/2017, was for “Infectious Diseases and Infection Control” and was not a nursing-facility-specific IP training. The report states that this failure could affect residents by placing them at risk of infection spread due to the facility not appropriately recognizing and responding to communicable diseases and infections.
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