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Based on interview and personnel record review, the facility failed to demonstrate the appointed Infection Preventionist was qualified through education, training, experience or certification in infection prevention and control.

The findings include:

A review of the personnel record for Staff E, Chief Nursing Officer was completed. During the record review, there was no evidence of training, or certification in infection control and infection, other than the routine infection control training provided to all staff.

An interview was conducted on 8/3/22 at approximately 9:45 AM, with Staff E, Chief Nursing Officer who confirmed she is responsible for the overall infection control and prevention program. Staff E confirmed she has not received any special training in infection control and prevention other than the regular annual training all staff are required to have.

Based on observations and interview, the facility failed to post signage specifying the rights of individuals with emergency medical conditions and women in labor in a conspicuous location within the Emergency Department (ED).

The findings include:

On 8/1/22 commencing at approximately 11:20 AM, an initial tour of the Emergency Department (ED), was conducted. No signage noting the rights of individuals with emergency conditions and women in labor was noted in the ED lobby.

On 8/1/22 at approximately 1:10 PM, and on 8/2/22 at approximately 2:32 PM, additional observations were made in the ED lobby, in treatment rooms 1, 2 and 3 and in the triage area. No signage noting the rights of individuals with emergency conditions and women in labor was noted.

On 8/3/22 at approximately 12:57 PM, an interview was conducted with the Plant Operations Director who confirmed the required signage was not posted in the ED until 8/3/22. The Plant Operations Director stated the signage was removed in 2018 for repairs to the ED and confirmed the signage was not replaced when the repairs were completed.