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Based on interviews and Facility document review the Facility failed to ensure the Chief Executive Officer (CEO), Chief Medical Officer (CMO) and President of the Medical Staff communicated recommendations of problems identified by the infection control officer to the medical staff and and assumed responsibility for the implementation of successful corrective action plans in affected problem areas.

This failure led to information related to the proliferation of infections not being timely communicated and an action plan not being timely developed.

FINDINGS:

According to the Facility's Medical Staff Bylaws;
Section 10.1.4 The Medical Staff shall ensure that the findings, conclusions, recommendations, and actions taken to improve organization performance are communicated to appropriate Medical staff Members and the Board of Governors.

Section 10.1.4.3, Medical Staff Participant Role in Performance Improvement: The Medical Staff shall participate in the measurement, assessment, and improvement of other patient care processes. Such activities shall include, but are not limited to a review of the following: 10.1.4.3.6 Surveillance of nosocomial/Hospital acquired infections.

1. The Facility did not ensure the recommendations of the Infection Control Officer were communicated to the Chief Medical Officer (CMO), other medical staff members and Board of Governors.

a) The Facility's infection control/prevention surveillance was reviewed on 10/09/13. The review revealed a cluster of Methicillin Resistant Staphylococcus Aureus (MRSA) infections had occurred during the month of June 2013.

b) On 10/09/13, the Facility's Infection control committee meeting minutes were reviewed for August 2013, the only meeting to occur since the cluster of infections in June. There was no evidence the cluster of infections was discussed in the meeting.

In an interview on 10/09/13 at 3:04 p.m., the Infection Preventionist (IP) confirmed the cluster of infections was not discussed in the committee meeting. The IP stated s/he had been on a leave of absence during the month of July and, although staff were assigned to cover his/her duties during this time, the cluster of infections was not discovered until his/her return in August.

Surgery Department & OR (Operating Room) Function Committee meeting minutes were reviewed for September 2013. The cluster of infections was not discussed and there was no documentation of discussion with leadership or in the staff huddle (a morning meeting held by the Facility).

c) In an interview on 10/09/13 at 3:04 p.m., The IP stated s/he developed a plan with the President of the medical staff to address the cluster of infections discovered. The IP stated the plan had been discussed with the operating room leadership and in the morning "huddle" with the operating room staff "last week" (which would have been the week of 10/1-10/4/13, three months after the infections had occurred). S/he confirmed s/he had not spoken with medical staff beyond the President of the medical staff about the issue.

However, there was no documentation which evidenced the cluster of infections had been discussed with the operating room leadership or staff.

d) In an interview on 10/11/13 at 11:22 a.m., the Chief Medical Officer (CMO) stated s/he did not know of the cases involving the cluster of infections described, but his/her expectation was that the medical staff would be informed and a plan of action be put in place.

e) In an interview on 10/11/13 the President of the Medical Staff admitted s/he had not yet discussed the issue of the cluster of infections with the entire medical staff. The President of the Medical Staff stated s/he had a plan to inform and educate the medical staff of issues related to infection control and prevention, however, the plan had not yet been actualized and s/he would bring the issue of the cluster of MRSA infections to the Medical Executive Committee at the next meeting, November 2013.

Based on interviews and Facility document review the Facility failed to ensure the Chief Executive Officer (CEO), Chief Medical Officer (CMO) and President of the Medical Staff communicated recommendations of problems identified by the infection control officer to the medical staff and and assumed responsibility for the implementation of successful corrective action plans in affected problem areas.

This failure led to information related to the proliferation of infections not being timely communicated and an action plan not being timely developed.

FINDINGS:

According to the Facility's Medical Staff Bylaws;
Section 10.1.4 The Medical Staff shall ensure that the findings, conclusions, recommendations, and actions taken to improve organization performance are communicated to appropriate Medical staff Members and the Board of Governors.

Section 10.1.4.3, Medical Staff Participant Role in Performance Improvement: The Medical Staff shall participate in the measurement, assessment, and improvement of other patient care processes. Such activities shall include, but are not limited to a review of the following: 10.1.4.3.6 Surveillance of nosocomial/Hospital acquired infections.

1. The Facility did not ensure the recommendations of the Infection Control Officer were communicated to the Chief Medical Officer (CMO), other medical staff members and Board of Governors.

a) The Facility's infection control/prevention surveillance was reviewed on 10/09/13. The review revealed a cluster of Methicillin Resistant Staphylococcus Aureus (MRSA) infections had occurred during the month of June 2013.

b) On 10/09/13, the Facility's Infection control committee meeting minutes were reviewed for August 2013, the only meeting to occur since the cluster of infections in June. There was no evidence the cluster of infections was discussed in the meeting.

In an interview on 10/09/13 at 3:04 p.m., the Infection Preventionist (IP) confirmed the cluster of infections was not discussed in the committee meeting. The IP stated s/he had been on a leave of absence during the month of July and, although staff were assigned to cover his/her duties during this time, the cluster of infections was not discovered until his/her return in August.

Surgery Department & OR (Operating Room) Function Committee meeting minutes were reviewed for September 2013. The cluster of infections was not discussed and there was no documentation of discussion with leadership or in the staff huddle (a morning meeting held by the Facility).

c) In an interview on 10/09/13 at 3:04 p.m., The IP stated s/he developed a plan with the President of the medical staff to address the cluster of infections discovered. The IP stated the plan had been discussed with the operating room leadership and in the morning "huddle" with the operating room staff "last week" (which would have been the week of 10/1-10/4/13, three months after the infections had occurred). S/he confirmed s/he had not spoken with medical staff beyond the President of the medical staff about the issue.

However, there was no documentation which evidenced the cluster of infections had been discussed with the operating room leadership or staff.

d) In an interview on 10/11/13 at 11:22 a.m., the Chief Medical Officer (CMO) stated s/he did not know of the cases involving the cluster of infections described, but his/her expectation was that the medical staff would be informed and a plan of action be put in place.

e) In an interview on 10/11/13 the President of the Medical Staff admitted s/he had not yet discussed the issue of the cluster of infections with the entire medical staff. The President of the Medical Staff stated s/he had a plan to inform and educate the medical staff of issues related to infection control and prevention, however, the plan had not yet been actualized and s/he would bring the issue of the cluster of MRSA infections to the Medical Executive Committee at the next meeting, November 2013.