HospitalInspections.org

Based on record review and staff interview the Hospital's medical staff failed to examine the credential files for 2 of 2 sampled contracted radiologists and failed to make recommendations to the governing body for approval and appointment to the medical staff membership (Provider AA and BB).

Findings included:

- Review of provider AA's credentialing file on 2/2/10 at 9:45am revealed medical staff granted temporary privileges to provider AA on 1/7/10. The file lacked evidence that medical staff reviewed and made recommendations to the governing body for final approval and appoint for privileges as a medical staff member.

- Review of provider BB's credentialing file on 2/2/10 at 10:15am revealed medical staff granted temporary privileges to provider BB on 1/7/10. The file lacked evidence that medical staff reviewed and made recommendations to the governing body for final approval and appointment for privileges as a medical staff member.

Interview with staff B on 2/2/10 at 10:20am acknowledged staff AA's credential files were on the agenda for medical staff meeting on 2/11/10 and the governing body meeting on 2/18/10 for approval and appointment for medical staff membership. Staff B stated that provider BB's credential file would not be reviewed until the March medical staff meeting and would be presented at the March governing body meeting for approval and appointment. Staff B confirmed the hospital failed to complete the credentialing process for 2 of 2 temporary credentialed providers.

- Staff B on 2/2/10 at 10:20am acknowledged the hospital had 19 other Radiologist's with temporary privileges. Staff B indicated the governing body will meet in March to approve the remaining 19 radiologists.

1.) Based on record review and staff interview, the infection control officer failed to provide evidence of monitoring, implementing infection control precautions and failed to follow infection control policies for patients identified with a potential infection for 8 of 20 sampled medical records (#'s 1, 2, 3, 4, 5, 7, 8 and 9).

Findings included:

- Document review on 2/2/10 of the policy titled "Guidelines for Isolation Precautions directed under H. "... Authorized prescriber/Registered Nurse 1. Shall write an order in the medical record to initiate isolation precautions based on known or suspected diseases. 2. Shall notify Infection Control for known or suspected organisms...4. Shall place a written order in the medical record to remove/discontinue ONLY after consulting with Infection Control or Director of Nursing or appropriate criteria are met...".

- Record review on 2/1/09 of patient #1, admitted on 1/25/10 with a diagnosis of confusion and agitation, revealed the Infection Control Screening Protocol completed on 1/25/10 identified the patient with a risk factor which required a nasal swab screening for Methicillin Resistant Staph Aureus (MRSA). The results of the nasal swab revealed a negative MRSA culture. The patient's medical record lacked evidence the nurse wrote an order to initiate or discontinue isolation. The record also lacked evidence the hospital placed the patient in isolation or discharged the patient from isolation.

- Record review on 2/1/09 of patient #2, admitted on 1/21/10 with a diagnosis of depressive anxiety, revealed the Infection Control Screening Protocol completed on 1/21/10 identified the patient with a risk factor which required a nasal swab screening for MRSA. The results of the nasal swab revealed a negative MRSA culture. The patient's medical record lacked evidence the nurse wrote an order to initiate or discontinue isolation. The record also lacked evidence the hospital placed the patient in isolation or discharged the patient from isolation.

- Record review on 2/1/09 of patient #3, admitted on 1/26/10 with a diagnosis of Bi-polar with anxiety, revealed the Infection Control Screening Protocol completed on 1/26/10 identified the patient with a risk factor which required a nasal swab screening for MRSA. The results of the nasal swab revealed a negative MRSA culture. The patient's medical record lacked evidence the nurse wrote an order to initiate or discontinue isolation. The record also lacked evidence the hospital placed the patient in isolation or discharged the patient from isolation.

Interview on 2/2/10 at 3:45pm with staff C and staff D verified when the hospital's Infection Control Screening Protocol identified a patient with a risk factor requiring culture screening, the hospital placed the patient in isolation at that time and the patient remained in isolation until the laboratory reported the culture results. Both staff C and staff D acknowledged staff does not "formally" document in the patient's medical record when the patient was placed in isolation or when the isolation was discontinued.

This deficient practice also affected patient #'s 4, 5, 7, 8 and 9.

2.) Based on record review and staff interview, the infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control precautions for 3 of 3 Obstetrical patients sampled (#'s 11, 12 and 13).

Findings included:

- Record review on 2/1/10 and 2/2/10 of patient #11, admitted on 1/2/10 and discharged on 1/3/10 for childbirth, revealed staff failed to implement the hospital approved Infection Control Screening Protocol. Patient #11's medical record identified the patient with a positive Group B Streptococcus infection on 12/31/09 and again on 1/2/10.

- Record review on 2/1/10 and 2/2/10 of patient #12, admitted on 1/4/10 and discharged on 1/6/10 for childbirth, revealed staff failed to implement the hospital's approved Infection Control Screening Protocol.

- Record review on 2/1/10 and 2/2/10 of patient #14, admitted on 12/28/10 and discharged on 12/30/09 for childbirth, revealed staff failed to implement the hospital's approved Infection Control Screening Protocol.

Interview on 2/2/10 at 2:00pm with Administrative staff A acknowledged the facility failed to include the Obstetrical Unit in the hospital wide infection control screening. The hospital failed to include patient #11 in the hospital's infection control surveillance.

The Infection Control Policy titled "Surveillance Policy Infection Control" failed to direct staff to complete an Infection Control Screening Protocol on all patients admitted to the hospital for inclusion in the infection control system to identify, report, investigate, monitor, and implement infection control precautions.

The hospital failed to include all patients in the hospital's infection control system for identifying, reporting, investigation, monitoring, and implementing infection control precautions.






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21997

Based on record review and interview the hospital's infection control officer failed to maintain an up-to-date log of incidents related to infections and communicable disease including data from all patients for three of twenty patients included in the sample (patient #7, 9, and 11).

Findings included:

- Hospital Policy "Identifying, Investigating, and Reporting Process" with the effective date of 12/3/09 instructed:

"The Infection Control Practitioner should identify patients at risk for infections by surveillance of admissions, provide investigation as necessary, and maintain a listing log of all patients with infections.

Patients will be screened upon admission by nursing staff for risk factors that contribute to infection by utilizing established infection screening protocols.

Nursing staff should report all patients admitted with signs and symptoms of infection to Infection Control.

Infection Control shall investigate each patient infection case (by chart review, surveillance of lab and positive culture reports, and infection control consultation) to determine additional measures to implement and to prevent the spread of infection."


- The hospital admitted patient # 7 on 12/22/09 with abdominal pain to determine if the patient had a viral gastritis or kidney stones. The hospital followed their infection prevention protocol (screen) with patient #7 and determined a nasal swab was necessary to determine if the patient was positive for multi-drug-resistant-organisms. The infection control officer's line listing (log) of patient surveillance for infections on 2/2/10 failed to include patient #7.

Nursing staff A on 2/2/10 review the infection control log and indicated the hospital just "missed" listing patient #7.

- The hospital admitted patient #9 on 1/21/10 with diagnosis of nausea/vomiting due to Gilberts syndrome. The hospital followed their infection prevention protocol (screen) with patient #9 and determined a nasal swab was necessary to determine if the patient was positive for multi-drug-resistant-organisms. The infection control officer's log of patient surveillance for infections on 2/2/10 failed to include patient #9.

- The hospital admitted patient #11 on 1/2/10 for child birth. The medical record contained a copy of the patient's pre-natal laboratory results which identified the patient was Group B Streptococcus positive. Subsequent documentation by hospital staff on 1/2/10 under laboratory findings documented the patient was positive for Group B Streptococcus.

The infection control log provided on 2/2/10 failed to list patient #11. Nursing Staff A acknowledged the hospital failed to include the obstetrical department in the infection control surveillance.