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Based on record review and interview the hospital's governing body failed to promptly ensure that an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained as a result of 3 sampled patients #10, #11, and #12, who developed in-house infections in the Medical Intensive Care Unit (M.I.C.U) and those patients identified in the National Healthcare Safety Network (NHSN) reports.

Findings include:

Clinical record review conducted from 06-04-13 thru 06-06-13 of sample patient (SP) #10 revealed that the patient was admitted to the facility on 02-25-13 with chief complaint of status post fall and altered mental status. Review of the Blood culture collected on 03/05/2013 revealed that it was positive for Staphylococcus Aureus which was reported as located in the central line .

Clinical record review conducted from 06-04-13 thru 06-06-13 of SP#11 revealed that the patient was admitted at the facility on 02/16/2013 with diagnosis of Acute Myeloleukemia-M4. Review of the Blood culture collected on 02/24/2013 at 09:16 am revealed Klebsiella Pneumoniae infection from the blood right A line.

Clinical record review conducted from 06-04-13 thru 06-06-13 of SP#12 revealed that the patient was admitted to the facility on 01-12-13 with diagnosis of massive gastro intestinal bleeding. Review of the Blood culture collected on 01/21/2013 at 17:27 revealed a stenotrophomonas Maltophilia and enterococcus faecalis infection at the specimen source: catheter tip.

Review of records conducted on 06-04-2013 to 06-06-2013 of the facility Infection Control Committee Meeting Minutes for March 26, 2013 revealed that there was no infection control rate or incidents related to above findings discussed in the meeting for this facility. The concerns of the FMQAI (Florida Medical Quality Assurance, Inc.) regarding the elevated facility infection control rates for CLABSI in MICU as reported in the CDC (Centers for Disease Control and Prevention) National Healthcare Safety Network (NHSN) were not addressed in the meeting. Review of the Infection Control log showed for January 1.9%, February 6.8%, and March 3.1%, 2013 for MICU for CLABSI rate, respectively.

Review of the facility ' s 2013 JHS Infection Prevention & Control Plan revealed: (v.) Infection Control Committee (ICC), (c) Meetings-1. The infection control will meet quarterly or as needed at the discretion of the ICC Chair.

Interview with the facility Infection Control Medical Director conducted on 06-10-2013 at 11:34 am via telephone confirmed above findings that the quarterly Infection Control Meeting was done for March, 2013 for other facilities but this facility was not included in the meeting. She further stated that there was an emergency meeting called to address the rising number of central line associated bloodstream infections in MICU. Review of her note to this surveyor dated 06-10-2013 showed: " VP of Quality, Associate Medical Officer, Nursing Director of MICU, Infection Preventionist and Medical Director for Infection Control attended this meeting. Even though there are no written minutes, the measures agreed during this meeting were reflected in my monthly Infection Control report to the hospital leadership later that month. "

Record review revealed that the facility had completed a Root Cause Analysis and Action Plan in response to the FMQAI (Florida Medical Quality Assurance, Inc.) analysis of data for the facility ' s MICU (Medical Intensive Care Unit) as reported in the CDC (Centers for Disease Control and Prevention) and National Healthcare Safety Network (NHSN), on 05/23/2013 prior to the survey. The facility start date for most of the actions to be taken by the facility were dated to begin April 2013 except for the Medical Team online orientation which was dated to begin in January 2013.

Interview with the Nurse Manager, Director of Critical Care Services and Chief Nursing Officer (CNO) conducted on 06-06-13 at 3:00 pm confirmed above findings and that they all are responsible for compliance of all the above plan of action regarding infection control on CLABSI, CAUTI, VAP and other Hospital Acquired Infections. That the Director of CCU is responsible to oversee all critical care units which will allow sharing and standardization of best practices to improve care within the critical care division especially MICU. That in the absence of the MICU Nurse Manager, the Director of Critical Care Services and the Critical Care Nurse Educator to take ownership of all the action plan. The CNO is to attend the ICC (Infection Control Committee) Meetings and assigned designee during her absence. The CNO stated that all Nursing leadership will have education on how to perform Quality Assessment and Quality Improvement effectively to prevent HAI (Healthcare Associated Infections.

The facility completed a Root Cause Analysis and Action Plan revised on 02/27/2013 in response to the FMQAI (Florida Medical Quality Assurance, Inc.) analysis of data for the facility ' s MICU (Medical Intensive Care Unit) as reported in the CDC (Centers for Disease Control and Prevention) and National Healthcare Safety Network (NHSN).

The corrective measures were noted as follows:
? Infection Control Prevention to round twice a week on maintenance including dressing line change, direct observation of accessing lines, site appropriateness and cleaning practices. Nurse Manager and Charge Nurses in MICU to perform rounds three days a week. Data being trended. ( Ongoing)
? All CLABSI (Central Line Associated Blood Stream Infection) were reviewed from January to April, 2013. Template and process created to review each hospital acquired infection (HAI). Each HAI will be reviewed collaboratively with MICU staff nurses, MICU Nurse Manager (NM), Assistant Nurse Manager, ICU (Intensive Care Unit) Nursing Director and Medical Team. Results will be reviewed within 5 days from date of notification. (Ongoing))
? Education with staff regarding consistent use of CLABSI, CAUTI (Catheter Associated Urinary Tract Infection), VAP (Ventilator Associated Pneumonia) bundles. An assessment and evaluation tool will be utilized signed by an employee and NM. Knowledge deficits will be identified with immediate remediation. (Ongoing)
? Chlorhexidine bathing of all patients in the ICU is being done as facility practice. Create and implement policy on Chlorhexidine to ensure consistency of practice. (Ongoing)
? Revision of Policy and Procedure regarding Vascular Access Devices: Care and Maintenance with Use of Curos cap education and implementation completed. Infection Control round twice a week and NM and Charge Nurses in MICU to round three times a week. (Ongoing)
? Use of Sorbaview dressing to maintain integrity of internal jugular central lines and other vascular access devices completed. Infection Control to round twice a week and Nurse Manager and nurse leader to round three times a week. (Ongoing)
? Medical Team orientation via JMH on line educational learning system (JEN) annually. Medical Team involvement with each CLABSI case review. (Ongoing)
? Vascular Access Devices for dialysis catheters policy and procedures completed. Education and evaluation for competency of Dialysis Registered Nurses (ongoing).
? Compliance on Infection Control bundles, line necessity and appropriateness of site, rounding log/tool completed and rounding ongoing. Data collected via Performance Improvement tool and analyzed on May. (Ongoing)
? Communication boards updated monthly and emails being sent including infection rates. Huddles and staff meetings done as new results are available. (Ongoing)
? Obtain positive blood cultures and review by leadership within 5 days of report. (Ongoing)

The facility also implemented the following corrective actions.


? The MICU staff meeting April 2013 notes include the March 2013 CLABSI and the CAUTI cases.
? An Email dated May 9, 2013 with a subject: important information concerning Chlorhexidine daily baths was sent to surgical intensive care (SICU) staff outlining the proper procedure concerning the Chlorhexidine daily baths.
? The MICU staff: Huddle Talking Points dated 05/13/2013 included the CLABSI and the CAUTI bundles
? MICU (Medical Intensive Care Unit) staff in-service on care and maintenance of central lines completed between 05/23/2013-06/03/2013. A Critical Care Town Meeting (MICU/SICU) dated 05/31/2013 included the Hospital Acquired Infections (HAI).
? Education on Infection Control : CLABSI Prevention 2013 of the MICU nursing staff began in April 2013
? MICU inservices on the topic: CUROS was completed on 04/22/2013 - 04/27/2013
? MICU audits were completed on 04/24/2013, 05/06/2013, 05/08/2013,05/22/2013, and 05/29/2013
? IMCU-C6 Inservices on the topic: Sorbaview Dressing was completed on 05/28-5/31/2013
? A Hospital wide Infection Control Prevention education was completed during April 2013 and May 2013.
? Daily rounding logs : 05/06/2013, 05/7/2013, 05/08/2013, 05/11/2013, 05/12/2013, 05/13/2013, 05/16/2013, 05/17/2013, 05/17/2013, 05/23/2013, 06/10/2013, and an Analysis of the daily rounding log was completed May 2013
? An observation of the MICU Round Board during the survey included the MICU acquired infections
? Review of the Policy was updated on 04/22/2013 with the subject Vascular Access Devices (VAD): Care And Maintenance protocol, a hospital wide PICC training for CLABSI reduction with a start date of 04/15/2013 took place during the month of April 2013 and May 2013.

Review of the education/in-services log and signing-in sheets for Prevention of CLABSI, CAUTI, VAP, Use of Curos cap, Vascular Access Device Dressing change, Daily Chlorhexidine bath, compliance with Computerized central line checklist, including policies and procedures conducted from 06-04-13 to 06-06-13 confirmed above findings that the plan of action for reducing HAI rates were done and still ongoing.

Based on record review and interview the hospital failed to ensure that the hospital-wide infection control quality assurance program promptly address the problems identified, and to be responsible for the prompt implementation of an effective corrective action plan as a result of 3 sampled patients #10, #11, and #12, who developed in-house infections in the Medical Intensive Care Unit (M.I.C.U) and those patients identified in the National Healthcare Safety Network (NHSN) reports.

Findings include:


Clinical record review conducted from 06-04-13 thru 06-06-13 of sample patient (SP) #10 revealed that the patient was admitted to the facility on 02-25-13 with chief complaint of status post fall and altered mental status. Review of the Blood culture collected on 03/05/2013 revealed that it was positive for Staphylococcus Aureus which was reported as located in the central line .

Clinical record review conducted from 06-04-13 thru 06-06-13 of SP#11 revealed that the patient was admitted at the facility on 02/16/2013 with diagnosis of Acute Myeloleukemia-M4. Review of the Blood culture collected on 02/24/2013 at 09:16 am revealed Klebsiella Pneumoniae infection from the blood right A line.

Clinical record review conducted from 06-04-13 thru 06-06-13 of SP#12 revealed that the patient was admitted to the facility on 01-12-13 with diagnosis of massive gastro intestinal bleeding. Review of the Blood culture collected on 01/21/2013 at 17:27 revealed a stenotrophomonas Maltophilia and enterococcus faecalis infection at the specimen source: catheter tip.

Review of records conducted on 06-04-2013 to 06-06-2013 of the facility Infection Control Committee Meeting Minutes for March 26, 2013 revealed that there was no infection control rate or incidents related to above findings discussed in the meeting for this facility. The concerns of the FMQAI (Florida Medical Quality Assurance, Inc.) regarding the elevated facility infection control rates for CLABSI in MICU as reported in the CDC (Centers for Disease Control and Prevention) National Healthcare Safety Network (NHSN) were not addressed in the meeting. Review of the Infection Control log showed for January1.9%, February 6.8%, and March 3.1%, 2013 for MICU for CLABSI rate, respectively.

Review of the facility ' s 2013 JHS Infection Prevention & Control Plan revealed: (v.) Infection Control Committee (ICC), (c) Meetings-1. The infection control will meet quarterly or as needed at the discretion of the ICC Chair.

Interview with the facility Infection Control Medical Director conducted on 06-10-2013 at 11:34 am via telephone confirmed above findings that the quarterly Infection Control Meeting was done for March, 2013 for other facilities but this facility was not included in the meeting. She further stated that there was an emergency meeting called to address the rising number of central line associated bloodstream infections in MICU. Review of her note to this surveyor dated 06-10-2013 showed: " VP of Quality, Associate Medical Officer, Nursing Director of MICU, Infection Preventionist and Medical Director for Infection Control attended this meeting. Even though there are no written minutes, the measures agreed during this meeting were reflected in my monthly Infection Control report to the hospital leadership later that month. "

Record review revealed that the facility had completed a Root Cause Analysis and Action Plan in response to the FMQAI (Florida Medical Quality Assurance, Inc.) analysis of data for the facility ' s MICU (Medical Intensive Care Unit) as reported in the CDC (Centers for Disease Control and Prevention) and National Healthcare Safety Network (NHSN), on 05/23/2013 prior to the survey. The facility start date for most of the actions to be taken by the facility were dated to begin April 2013 except for the Medical Team online orientation which was dated to begin in January 2013.

Interview with the Nurse Manager, Director of Critical Care Services and Chief Nursing Officer (CNO) conducted on 06-06-13 at 3:00 pm confirmed above findings and that they all are responsible for compliance of all the above plan of action regarding infection control on CLABSI, CAUTI, VAP and other Hospital Acquired Infections. That the Director of CCU is responsible to oversee all critical care units which will allow sharing and standardization of best practices to improve care within the critical care division especially MICU. That in the absence of the MICU Nurse Manager, the Director of Critical Care Services and the Critical Care Nurse Educator to take ownership of all the action plan. The CNO is to attend the ICC (Infection Control Committee) Meetings and assigned designee during her absence. The CNO stated that all Nursing leadership will have education on how to perform Quality Assessment and Quality Improvement effectively to prevent HAI (Healthcare Associated Infections.