HospitalInspections.org

Based on a review of documentation, the facility failed to review the policies at least annually.

Findings were:

During a review of facility policies, the following policies lacked current review:
· Medical Records Policies and Procedures - last reviewed 8-5-14
· Personnel Policies - last reviewed 7-2014 (no specific day noted)
· Fire Emergency & Disaster Policies and Procedures - last reviewed 2-24-11

The following was confirmed in an interview with the Chief Executive Officer and other administrative staff on the afternoon of 10-19-16.

Based on a review of documentation and an interview with staff, the facility failed to develop a facility-wide system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.

Findings were:

In an interview with staff #4, staff #4 stated that [staff #4] and staff #2 were the designated infection control nurses and handled the infection control program for the facility.

A review of the personnel files for staff #2 and staff #4 revealed no training or experience in infection control. In an additional interview with staff #4, [staff #4] confirmed that neither nurse had training or prior experience in infection control.

The above was confirmed in an interview with the Chief Executive Officer and other administrative staff on the afternoon of 10-29-16.