HospitalInspections.org

Based on document review and interview, the facility failed to follow their policy and procedure related to having an active surveillance technique to monitor pest sightings for eight (8) of eight (8) months.

Findings include:

1. Review of the hospital policy titled, "Pest Control", policy number III-B.53, date issued 10/2014, indicated the purpose of the policy was to create a pest free environment. "Pests encountered in health care premises...have the ability to carry bacteria within their gut or on their bodies." The Chief Executive Officer and/or Maintenance staff should "receive all reports of sightings or evidence of pests". At that time "they will enter the details of such notifications into the Pest Sighting log". This policy was last revised on 10/2017.

2. Review of the hospital policy titled, "Infection Control Scope of Service", policy number III-D.31, date issued 10/2014, indicated the "infection control program is comprehensive in that it addresses detection, prevention, and control" of infections involving all departments and services (Environment of Care). This policy was last reviewed 01/2017.

3. Requested pest sighting logs for the time period of 01/01/2018 through 08/31/2018. Facility staff were unable to locate and/or provide required logs.

4. In interview on 08/31/2018 at approximately 11:38 am with environmental staff member EV # 3, confirmed the "pest sighting logs were missing".

5. In interview on 08/31/2018 at approximately 3:30 pm with administrative staff member A # 5 (Chief Executive Officer-CEO), confirmed "we" the facility "are supposed to have a log".

6. No further documentation was provided to this surveyor prior to exit on 08/31/2018 at approximately 4:15 pm.