Failure to Provide and Document Required Infection Control Training for Clinical Staff
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff received mandatory infection prevention and control education as required by its infection control program and staff development policies. A registered nurse hired in early August 2024 had a personnel file that included a signed job description and a general new employee orientation acknowledgment, but there was no documentation specifying what training topics were covered, and no evidence that infection control training had been completed. Review of the in-service training log and the facility’s electronic training system, confirmed by the HR representative, showed that infection control training was neither assigned nor completed for this nurse at the time of survey. A similar lack of documentation was found for an LPN hired in September 2016. The LPN’s personnel file contained a signed job description requiring participation in all required trainings, but there was no evidence of completed infection control training. The HR representative and surveyor verified in the training system that infection control training had not been assigned or completed for this LPN. After survey exit, the facility submitted an email with an attached “Clinical Staff Annual Education” roster listing both the RN and LPN with handwritten check marks indicating training completion, but the document did not clearly indicate when the training occurred or provide specific dates of completion. Additional staff interviews supported the finding that infection control education was not consistently provided or documented. An LPN reported that staff receive monthly in-services and annual computer-based training and stated that training on infection control is important so staff do not spread infections. A CNA, described as relatively new, reported receiving on-the-job training but no infection control training, and was told there would be online training to complete within two months. The DON stated that staff are expected to complete onboarding orientation and periodic education throughout the year, and emphasized that infection control training is important to prevent knowledge deficits that could delay responses and impact care. Facility policies and the facility assessment specified that infection control education is mandatory on hire and annually, and that infection control is a required competency to be started during orientation and completed within the first weeks of hire and then annually, but the documented practices for the identified staff did not align with these requirements.
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