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Review of the infection control data and interview with staff the hospital failed to meet the Condition of Participation for Provision of Services as evidenced by:

1) failing to develop and implement an infection control program and system for the prevention, control, and investigation of infections and communicable diseases of patients (See tag C278),

2) failing to have a qualified infection control officer responsible for surveillance activity and investigation of any potential outbreaks, hospital and medical staff education, and ongoing analysis and trending of infections (see tag C278),

3) failing to include infection control reporting through the Quality Assurance program. (See tag C337

Based on review of the infection control plan and infection control data and interview with staff the hospital failed to develop a program for identifying, reporting and controlling infections by failing to: 1) develop and implement an infection control program for the prevention, control, and investigation of infections and communicable diseases of patients, 2) to have a qualified infection control officer and 3) include infection control reporting through the Quality Assurance program. Findings:


Review of the the infection control plan provided to the survey team by the DON (director of nursing services) failed to reveal the hospital had an infection control program for patients. In an interview on 11/16/2010 at 10:00 AM S2 RN stated she was appointed to as the infection control officer "about one month ago and I was just reading up on my duties". She further stated the only infection control experience she had was working as a RN (registered nurse) on the medical surgical unit. S2 reported that S1 DON gave her the the infection control manual and she (S2) "discovered" that it did not have a plan for identifying, reporting and controlling infections. She also reported that the manual only addressed employee health and had not been reviewed or revised since 2006.

An interview was held on 11/16/2010 at 9:45 AM with LPN S3 who stated she started in March or April of 2010 collecting data on patients for infection control purposes but she was not the infection control officer. Further interview revealed she would go to the Lab, gather information on patients who had cultures and place this information on the DON's desk. She said she did not collect data on other patients who had signs and symptoms of infections. Additionally, S3 said she stopped collecting this information about 3 weeks ago.

In an interview on 11/16/2010 at 10:00 AM the DON stated she was the previous infection control officer and confirmed that the hospital did not have a program that addressed patient infections. She also confirmed that RN S2 was the infection control officer and that she (S2) did not have any experience as an infection control officer neither was she trained or in-serviced in this area. Further interview revealed infections had not been tracked, trended or reported in the Quality Assurance program from 12/09 until present.

Based on review of Governing Body meeting minutes and the Infection Control plan (only included employee health) and interview with staff the Governing Body failed to review and revise the infection control plan at least annually. Findings:

Review of the Governing Body meeting minutes for the last year and the infection control manual revealed no documented evidence that the infection control manual was reviewed, revised or evaluated since 2006. In an interview on 11/16/2010 at 10:00 AM the DON confirmed the Infection Control manual had not been approved by the Governing Body since 2006.

Based on review of 1 of 1 medical records of patients with a hemodialysis port (#21) in a total sample of 22 and interview with nursing staff, the hospital failed to ensure each patient care needs were met by not identifying and assessing the hemodialysis access site of a patient. Findings:

Review of the open medical record of patient #21 revealed she was admitted on 11/12/10 with diagnosis that included a new onset of edema in the right lower extremity- presumptive deep vein thrombosis, End Stage Renal Disease that required hemodialysis 3 times a week, diabetes mellitus, End Stage Chronic Obstructive Pulmonary Disease, coronary artery disease, and a history of hypertension.

Review of the General Admission Information assessment completed by the admitting RN on 11/12/2010 revealed patient #21 was identified as a dialysis patient. Further review revealed the RN failed to identify and assess the hemodialysis access site. Review of the daily nurse note entries in the electronic record on 11/13/10 and 11/14/10 failed to reveal documentation the dialysis access site was included in the RN assessment.

Interview on 11/16/2010 at 12:15 PM with S5 RN confirmed the dialysis access site was not identified or assessed on admission and that there was no documented evidence the access site was assessed on 11/13/10 and 11/14/10. When asked when patient #21 last received dialysis, S5 RN stated patient #21 received dialysis on Friday, 11/12/10, the day she was admitted.

Based on review of 1 of 1 medical record of patients with a hemodialysis access site in a total sample of 22 and staff interview, the hospital failed to develop nursing care plans approaches for all patients based on the assessment of needs by not identifying and documenting on admission that patient #21 had a hemodialysis access site. Findings:

Review of the open medical record of patient #21 revealed she was admitted 11/12/2010 with diagnoses that included a new onset of edema in the right lower extremity, presumptive deep vein thrombosis, End Stage Renal Disease that required hemodialysis 3 times a week, diabetes mellitus, End Stage Chronic Obstructive Pulmonary Disease, coronary artery disease, and a history of hypertension.

Review of the General Admission Information assessment completed by the admitting RN on 11/12/2010 revealed patient #21 was identified as a dialysis patient. Further review revealed the RN failed to identify and assess the patient's hemodialysis access site. Review of the electronic daily nurses' notes dated 11/13/2010 and 11/14/2010 failed to reveal documentation that the dialysis access site was included in the RN assessment.

Interview on 11/16/2010 at 12:15 PM with S5 RN confirmed the dialysis access site was not identified or assessed on admission by the RN and that the medical record failed to reveal a care plan was developed and implemented to address the access site.

Based on review of QA (Quality Assurance) meeting minutes from 12/25/2009 through 7/13/2010 and interviews, the hospital failed to have an effective QA/PI program that evaluates/monitors/ and reports the quality and appropriateness of all services as evidenced by the failure to include housekeeping services and infection control in the QA program, both of which affect the health and safety of all patients. Findings:

Review of QA/PI meeting minutes from 9/25/2010 through 7/13/2010 failed to reveal infection control information was reported in the meetings. In an interview on 11/15/2010 at 2:45 PM S1 DON reported she had not tracked, trended, or reported patient infections to the Quality Assurance committee for the past year. S1 further stated she did not have time to copy the results of cultures from the Lab log because that was how she tracked infections. S1 added that due to failure of the hospital to track infections, she did not know the hospital's nosocomial rate. was.

Further review of QA/PI meeting minutes for 12/25/2010 through 7/13/2010 failed to reveal housekeeping data was reported during the meetings. In an interview on 11/15/2010 at 3:50 PM S6, environmental services director, reported that he does not track quality indicators for housekeeping services and does not report data from that department.

Based on record review and staff interviews the hospital failed to have a system in place to ensure nosocomial infections were evaluated by not having an infection control program that addressed patients. Findings:

Review of the the infection control plan provided to the survey team by the DON (director of nursing services) failed to reveal the hospital had an infection control program that addressed patients infections. In an interview on 11/16/2010 at 10:00 AM S2 RN stated the hospital did not have a plan for identifying, reporting and controlling infections.

An interview was held on 11/16/2010 at 9:45 AM with LPN S3 who stated she started in March or April of 2010 collecting data on patients for infection control purposes but she was not the infection control officer. Further interview revealed she would go to the Lab, gather information on patients who had cultures and place this information on the DON's desk. She said she did not collect data on other patients who had signs and symptoms of infections. Additionally, S3 said she stopped collecting this information about 3 weeks ago.

In an interview on 11/16/2010 at 10:00 AM the DON stated she was the previous infection control officer and confirmed that the hospital did not currently have a program that addressed patient infections. Review of QA meeting minutes from 12/25/2009 through 7/13/2010 failed to reveal infection control information was reported in the meetings. In an interview on 11/15/2010 at 2:45 PM S1 DON reported she had not tracked, trended, or reported patient infections to the Quality Assurance committee for the past year. S1 added that due to the failure of the hospital to track infections, she not the hospital's nosocomial infection rate.

Review of QA/PI meeting minutes from 9/25/2010 through 7/13/2010 failed to reveal infection control information was reported in the meetings. In an interview on 11/15/2010 at 2:45 PM S1 DON reported she had not tracked, trended, or reported patient infections to the Quality Assurance committee for the past year. S1 further stated she did not have time to copy the results of cultures from the Lab log because that was how she tracked infections. S1 added that due to failure of the hospital to track infections, she did not know the hospital's nosocomial rate. was.