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Based on observation, record review, and staff interview, the hospital's infection control program failed to:

A. provide documentation of the program's surveillance, prevention, and control activities.

B. ensure active tracking and trending of infection control surveillance within the hospital.

C. ensure communication and collaboration with the hospital's QAPI (Quality Assurance and Performance Improvement) Program and follow the hospital's 2024 Infection Control Program Plan.

These deficient practices had the likelihood of causing harm, serious injury, or death to the patients receiving care at the hospital due to the hospital's inactive surveillance, prevention, and control activities.

Findings included:

A.

Staff #21 reported surveillance rounds are conducted every 6 months in clinical areas of the hospital. On 3/04/2024 and 03/05/2024 the surveyor requested documented proof of surveillance activities that occurred in 2023 for clinical areas. The hospital's ICP (Infection Control Preventionist) Staff # 21 was unable to provide documentation (written or electronic) of surveillance activities.

A review of the hospital document titled, "Patient and Environmental Safety Committee Environment of Care Rounding Tool" revealed Staff #21 had conducted an environmental round in the dietary department on 12/08/2023. Staff #21 documented, "No opportunity to observe" dietary staff's PPE (personal protective equipment) compliance.

In an interview with Staff #21 on 03/05/2024 at 3:30 PM, Staff # 21 was asked if hairnets and gloves qualified as PPE for dietary staff. Staff #21 stated, "Oh, I guess I didn't think of hair nets as PPE. I should have observed that." When questioned about tracking and trending for hospital surveillance, Staff # 21 stated, "There is not any tracking and trending, and I don't keep up with percentages. I tour departments with the unit directors or environmental services or both and I do take some notes while touring. All items that can be corrected immediately are corrected or a work order is put in."

B.

A review of the hospital document titled, "Performance Improvement Monthly Trending Report Fiscal Year 2023" revealed Patient # 7 had a total hip replacement in April of 2023 and was readmitted to the hospital within 30 days for a positive wound culture and incision and drainage of the surgical site.

An interview with Staff #44 (Hip and Joint Program Coordinator) on 03/06/2024 at 3:00 PM confirmed Patient #7 had one SSI (surgical site infection) in 2023. Staff #44 was asked how the infection preventionist was made aware of the SSI. Staff #44 stated, "I picked up the phone and called her". There was no evidence of a bi-monthly report provided to the ICP as required in the hospital's "Infection Prevention and Control Plan 2024".

A review of the hospital document titled, "2023 Infection Prevention and Control" revealed Staff #21 did not document and track the SSI that occurred in Patient #7.

An interview with Staff #21 on 03/06/2024 at 4:00 PM confirmed the ICP was unaware of Patient #7's SSI that occurred in 2023. Staff #21 stated, "I was not aware of an SSI for a total hip replacement patient".

A review of NHSN's (National HealthCare Safety Network) January 2024 Manual for Surgical Site Infection Event revealed the following,

"While advances have been made in infection control practices, including improved operating room ventilation, sterilization methods, barriers, surgical technique, and availability of January 2024 Procedure-associated Module SSI Events, SSIs remain a substantial cause of morbidity, prolonged hospitalization, and mortality ...
A successful surveillance program includes the use of epidemiologically sound infection definitions and effective surveillance methods, stratification of SSI rates according to risk factors associated with SSI development, and data feedback."

C.

A review of the hospital's Quality Council Meeting Minutes for August 9th, 2023 revealed the Infection Prevention and Control Program only reports to Quality bi-monthly. On the August 9th, 2023 Quality Council meeting, Staff #21 did not report 6 months of infection control and prevention data to the Quality Council. Staff #21 only reported data for June and July. Patient #7's SSI which occurred in April of 2023 was not reported to the Quality Council.

An interview with Staff #6 (Quality Director) on 03/05/2024 at 3:45 PM confirmed the hospital's infection control program only reports to the Quality Council every 6 months. The surveyor asked if 6 months of data and reporting is reviewed in the Quality Council meeting Staff #6 stated, "No the ICP will pick up the phone and call me if something unusual happens."

A review of the hospital's 2024 Infection Prevention & Control Plan revealed the following:

"OBJECTIVE:

There is an effective organization-wide program for the surveillance, prevention, and control of infections at Wadley Regional Medical Center (WRMC). A coordinated process is used to reduce the risks of endemic and epidemic healthcare-acquired infections in patients and healthcare workers, which is based on sound epidemiologic principles and research. Surveillance incorporates activities to identify, analyze, report, prevent, and control healthcare-acquired infections.

In developing and reviewing the program annually, factors such as patient population, WRMC geographic location, service lines and clinical focus, and the number of employees were considered. WRMC community environment serves a diverse patient population. Patients are cared for in many locations, including inpatient, outpatient, critical care, and clinics. Surgical procedures at WRMC range from minor room procedures to open heart surgeries. The age range of our patients varies from newborns to children and adolescents, to adults and senior adults. Each age group has unique risk factors for developing community and healthcare-acquired infections.

HAI SURVEILLANCE OVERVIEW:

The WRMC Infection Prevention & Control Program is responsible for monitoring HAIs. A targeted surveillance program for HAIs has been utilized at WRMC. With targeted surveillance, infection prevention & control outcome objectives are determined, priorities are established, and resources are allocated to the major types of infection and the patient populations at highest risk of acquiring HAI. Numerators and denominators are clearly established, ·with the focus on procedures having preventable risk factors that contribute to the development of HAI. Infections known at the time a patient is transferred will be reported to the receiving facility. Infections that are related to admission at a referring facility will be reported to that facility. In addition to the infection types specified in the targeted surveillance plan, non-targeted infections, single occurrences, and/or outbreaks of HAI related to any unusual or virulent pathogenic organism are evaluated. The Infection Preventionist/Infection Prevention & Control Committee determines interventions.

SURVEILLANCE STRATEGIES: Surgical Site Surveillance Component

All patients who undergo the following operative procedures are monitored for surgical site infection and reported to NHSN: Total knee and total hip replacement surgeries, lower limb vascular surgeries, colon or large intestine surgeries, hysterectomies, carotid endarterectomy, and abdominal aortic aneurysm repair. Cesarean Section procedures will be monitored though not required to be reported to NHSN.

Total Knee and Hip Replacement Surveillance:
Objectives:
To benchmark with established MISN rates and established WRMC historical baseline rate.
1. To identify HAI trends.
2. To evaluate procedures, policies, and practices, looking for preventable risk factors, when infection trends are identified.
3. To eliminate infections by reducing risk factors. Methodology:
4.The Infection Preventionist collects data on an ongoing basis.

*Numerator: Number of patients developing surgical site infection following total joint replacement surgery.
*Denominator: Total number of patients undergoing total joint replacement surgery.

Data Sources:

Monthly report of all total joint replacement procedures.
Daily admission report from the computer data systems.
Concurrent and/or retrospective chart review of each patient undergoing total joint replacement with post-discharge surveillance from orthopedic surgeons via follow-up letter.
Communication from the orthopedic nursing employees and/or Case Managers.

CDC.
Defining Indicators for Infections

Infection occurs following total joint replacement surgery at WIRMC.

CDC definition for surgical site infection. Follow-up.

I. Reports are provided bimonthly to the Infection Prevention & Control Committee and participating orthopedic surgeons and other committees with a personal stake in these rates when trends are identified.

When WRMC rates exceed the NHSN rate and/or established WRMC historical baseline rate, or a trend is identified; the Infection Preventionist decides as to significance.

If the infection rate is significant, an evaluation of relevant procedures, policies, and practices is undertaken by the Infection Preventionist, and other departments as designated.

A report is presented by the Infection Preventionist to the Infection Prevention & Control Committee describing the result of the evaluation.

If preventable risk factors are identified, an action plan will be put in place utilizing a team approach with all disciplines included.

High-Level Disinfection (HLD) is the process of complete elimination of all microorganisms in or on a device, except for small numbers of bacterial spores. It is the goal of WRMC to maintain 100% compliance in this area. Strategies to reach this goal will include, but are not limited to:
Continue education of staff and monitor processes.
Ensure proper PPE is available and worn.
Ultimately create an online education tool for annual training and assist with annual competencies.
Streamline competencies into an annual session.
Compliance will be monitored during Infection Prevention and Control EOC rounds."