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Based on record review and interview, the facility failed to maintain an ongoing infection control program designed to prevent, control and investigate infections and communicable diseases for 6 of 6 months reviewed, resulting in the potential for transmission of infectious agents for all patients served by the facility. See specific tags:

--A 0748: Failure to provide evidence that the Infection Control Preventionist's had access to an Infection Control Physician leader who was responsible for chairing the infection control and prevention committee and was available for guidance and oversight according to their 2021 Infection Control Plan.


-- A 0749 - 1. The facility failed perform staff surveillance and document compliance with hand hygiene for staff working off shifts (after 1900, and on weekends). 2. Failure to monitor and document compliance for staff donning and removing gloves. 3. Failure to monitor and document readmissions for organisms coming into the hospital according to their 2021 Infection Control Plan.

Based on record review and interview, the facility failed to provide evidence that the Infection Control Preventionist's had access to an Infection Control Physician leader who was responsible for chairing their infection control and prevention committee and was available for guidance and oversight as needed according to their 2021 Infection Control Plan, resulting in the potential for the spread of infections for all patients served by the facility.
Findings include:

On 3/17/2021 at 1130, review of the Infection Control Program was reviewed with Chief Nursing Officer/Interim Infection Control Preventionist (Staff B). At that time, Staff B explained he had been responsible for the Infection Control Program since December 2020. Staff B said he was a member of Association of Professional in Infection Control and Epidemiology (APIC).
Review of a document titled "APIC membership", revealed Staff B had joined APIC on 3/14/2011 and his membership was paid through 12/31/2021.

Further review of Staff B's Infection Control training experience revealed the following:
Completion of 24 contact hours on 4/7/2011 for education titled "Fundamental of Infection Surveillance Prevention and Control."
Annual facility required Infection Control Education dated 11/2019.
Completion of 1.5 contact hours on 2/15/2021 for education titled "Leadership and Management in Infection Prevention."

Review of the facility's Medical Executive Committee minutes revealed the Infection Control Committee was a subcommittee of the Medical Executive Committee that met quarterly. The last meeting was on 2/7/2021 according to Staff B. Staff B explained there was not a physician with expertise in Infection Control on the Medical Executive Committee nor on the Infection Control Committee available for guidance nor oversight.

Review of the facility "2021 Infection Prevention and Control/Antibiotic Stewardship Program", documented the following:
The general responsibilities of the infection control practitioner are listed below...and has access to an infection control physician leader who chairs the infection control and prevention committee and provides guidance.
(However, there no evidence provided that demonstrated this was done).

Based on record review and interview, the facility failed to 1) perform staff surveillance and document compliance with hand hygiene for staff working off shifts (between the hours of 1900 and 0730, and on weekends); 2) failed to monitor and document compliance for staff donning and removing gloves; and 3) failed to monitor and document readmissions for organisms coming into the hospital according to their 2021 Infection Control Plan resulting in the potential for the spread of infectious for all patients served by the facility.
Findings include:

An interview was conducted with patient #1 on 3/16/2021 at 1150 while accompanied by Inpatient Nurse Manager (Staff D) and Registered Nurse (Staff G). According to the patient she was in the hospital due to "complications from her prior surgery."
The patient said she was receiving intravenous (IV) antibiotics.

On 3/16/2021 at 1220 review of the medical record for patient #1 revealed the following:
Patient #1 was a 52-year old female readmitted to the facility on 3/11/2021 with diagnoses that included Cervical Tear and leak. Physician's orders included Vancomycin 1250 milligrams (antibiotic used for infections) IV every 12 hours.

On 3/17/2021 at 1130, review of the Infection Control Program was reviewed with the Chief Nursing Officer/Interim Infection Control Preventionist (Staff B), Staff D was also present and the following was revealed:

Review of the facility "2021 Infection Prevention and Control/Antibiotic Stewardship Program", documented the following:
Purpose; Preventing infections...Identify organisms of epidemiological importance coming into the hospital...
2021 Prioritized Goals; ...#2. Hand Hygiene compliance. Goal 90 percent (%).

Review of staff Infection Control surveillance logs dated December 2020-March 2021 revealed staff were only audited for hand hygiene during the day shift (0700-1930). There were no audits for staff working the evening shift (1900-0730) or on the weekends. There were no audits for staff donning or removing gloves on any shifts.

On 3/17/2021 at 1145, Staff D explained he was responsible for the surveillance of staff and performing audits. Staff D said he did not conduct audits for hand hygiene on the off shifts or weekends. Staff D said he did not conduct donning and removing gloves surveillance activities.

Further review of the Infection Control program revealed there was no evidence that surveillance activities were conducted for facility readmissions.

On 3/17/2021 at 1245, Staff B said he was not aware, nor tracking hospital readmissions as related to infection control concerns. Staff B explained he mainly tracked Surgical Site Infections (SSI's). He said data for January and February were pending receipt of "laboratory results", and any "queries (self-reported)" from all surgeons for those months were outstanding.

On 3/17/2021 at 1600, during an interview Medical Doctor Staff L was queried regarding how readmissions were investigated/evaluated/tracked as a means of identifying infections, tracking/trending for patterns, and preventing the spread of infections.

At that time Staff L replied, "Readmissions are treated as infections. He said readmissions for wound infections or wound swelling are treated as infections."
Staff additionally added that to his knowledge the last infection readmission that was positive for infection was November 2020.

Based on record review and interview, the facility failed to provide completed pre-surgical Medical History and Physical (H&P) for 1 (#9) of 10 patients whose surgical records were reviewed prior to receiving a surgical procedure requiring anesthesia, resulting in the potential for poor surgical patient outcomes. Findings include:

On 3/17/2021 at 1045, review of patient #9's medical record was conducted with Support Specialist (Staff K) and the Chief Nursing Officer (Staff B) and revealed the patient was a 64 year old female admitted on 02/26/2021 for a surgical procedure. Review of the form titled
"History & Physical" was incomplete. Dedicated spaces to address the following elements were left blank: "Proposed Surgery/Procedure, Present Complaint, Diagnosis, Past History and Allergies" were not addressed. The form was signed on 2/26/2021 at 0728.
However there were no other updates to the H&P documented in the medical record.

On 3/17/2021 at 1055, the Chief Nursing Officer confirmed a complete H&P was required prior to all surgical procedures. However, that was not done.

Based on record review and interview, the facility failed to ensure post anesthesia evaluations for patients who had received general anesthesia (medication that keeps an individual asleep during a procedure or surgery) were accurate, thoroughly completed and documented the time of those evaluations for 10 of 10 patients (#'s 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) whose records were reviewed, resulting in the potential for less than optimal outcomes for all patients served by the facility. Findings include:

On 03/17/2021 between the hours of 0900 and 1130 review of the electronic medical records for 10 patients (#'s 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) was conducted with Support Specialist Staff K. The Chief Nursing Officer Staff B and Inpatient Nurse Manager Staff D were also present and the following was revealed:

During record review, it was noted on the documents titled "Pre-Anesthetic Record" the Section titled "Discharge Evaluation (Anesthesia Discharge from PACU)" were incomplete. The discharges were signed by the Evaluator. However, there were no times that documented the actual time of the discharge evaluation.

Patient #1 was admitted on 2/24/2021 for a total disc replacement (surgical procedure on the spine requiring general anesthesia). The Discharge Evaluation was signed on 2/23/2021 (prior to admission). Additionally, there was no time documented on the post-op evaluation dated 2/23/2021.

Patient #2 was admitted on 3/10/2021 for a Transforaminal Lumbar Interbody Fusion (TLIF) (surgical procedure that fuses the bones of the spines under general anesthesia). The Discharge Evaluation was signed on 3/10/2021. However, there was no time documented on the post-op evaluation.

Patient #3 was admitted on 2/22/2021 for a post cervical fusion (surgical procedure performed on the back of the neck under general anesthesia). The Discharge Evaluation was signed on 2/22/2021. However, there was no time documented on the post-op evaluation.

Patient #4 was admitted on 3/4/2021 for a Transforaminal Lumbar Interbody Fusion (TLIF). The Discharge Evaluation was signed on 3/4/2021. However, there was no time documented on the post-op evaluation.

Patient #5 was admitted on 3/5/2021 for a (TLIF). The Discharge Evaluation was signed on 3/5/2021. However, there was no time documented on the post-op evaluation.

Patient #6 was admitted on 3/10/2021 for a (TLIF). The Discharge Evaluation was signed on 3/10/2021. However, there was no time documented on the post-op evaluation.

Patient #7 was admitted on 3/10/2021 for a Transforaminal Lumbar Interbody Fusion (TLIF). The Discharge Evaluation was signed on 3/10/2021. However, there was no time documented on the post-op evaluation.

Patient #8 was admitted on 3/12/2021 for a Total Disc Replacement. The Discharge Evaluation was signed on 3/12/2021. However, there was no time documented on the post-op evaluation.

Patient #9 was admitted on 2/26/2021 for Lumbar laminectomy (surgical procedure performed on a disc in the lower back under general anesthesia). The Discharge Evaluation was signed on 2/26/2021. However, there was no time documented on the post-op evaluation.

Patient #10 was admitted on 2/19/2021 for Lumbar laminectomy. The Discharge Evaluation was signed on 2/19/2021. However, there was no time documented on the post-op evaluation.

On 03/17/2021 at approximately 1135 during an interview with the Chief Nursing Officer the findings were confirmed. Additionally, at that time, it was determined there was no further documentation in the medical records that could confirm the time for those post-op evaluations.

A phone interview was conducted with the Chief of Staff (Staff M ) on 3/17/2021 at 1300 regarding the aforementioned concerns. At that time, Staff M replied, "there was a discussion, we are in the process of of discussing those concerns." Staff M explained there was only one Anesthesiologist (Staff O), she said it was expected that Staff O would be documenting the times on the Discharge Evaluations at the time of those assessments.