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Tag No.: C0270
Based on record review, staff interview and review of the policy and procedures for infection control program, the facility did not have an active surveillance program to prevent, early detection, control, education and investigation of infections and communicable diseases. This could affect all patients in the acute care hospital and the clinics that are served by this provider.
Findings include: The Condition of Participation: Provision of Services at C-0270 (?485.635) was not met.
Please cross reference C-0278 (?485.635(a)(3)(vi) A system for identifying, reporting, inve3stgation and controlling infections and communicable diseases of patients and personnel.
Tag No.: C0278
Based on record review, interview and review of infection control procedures and policies, the Critical Access Hospital (CAH) failed to maintain a surveillance system which includes a system to identify all infections both hospital acquired and those admitted with an exiting infection, reporting, investigation, and developing interventions to control infections and communicable diseases for all patients and personnel.
Findings include:
The infection control program did not include identify all infections that were acquired before entering the hospital nor all personnel infections and diseases, lacked tracking and analyzing trends of both nosocomial (hospital acquired) and non-nosocomial infections and communicable diseases, lacked a policy that defined communicable diseases, lacked an up to date tuberculosis policy that addressed prevention and control of transmission in all areas of the CAH and failed to administer two step tuberculosis skin testing according to current Centers for Disease Control and Prevention (CDC) guidelines.
During an interview on July 22, 2010, at 2:00 p.m., RN-A indicated that information regarding facility infections is shared during the Infection Control Committee meeting. These meetings were for 2010, were conducted on 2/18/10, and 4/15/10. Review of the infection control committee meeting minutes dated 2/18/10, showed the following information was presented: the nosocomial infection rate through November 2009, the total number of patients infected with Chlamydia, hepatitis C and hepatitis A or B in 2009 that were required to be reported to Minnesota Department of Health (MDH) and employee illnesses for 2009 that were considered infectious. Review of the Infection Prevention & Control Meeting minutes dated 4/15/10, showed the following information was presented: the nosocomial infection rate for January and February 2009/2010, MDH reportable infections for January through February and employee infectious illnesses for January through March 2010. The meeting minutes lacked the analysis, trending and reporting of the information relate to infections that were not hospital acquired. RN-A confirmed that no other information regarding infection surveillance was presented.
Review of the infection control " Internal Quality Log " for 2009 listed seventeen (17) patients with an infectious diagnosis and identified the treatment that was administered. All 17 patients had a post operative infection diagnosis and the log indicated 2 of these patients received their surgical procedure at another facility. No other infections for 2009 were included on this infection control log. An interview was conducted on 7/22/10, at 2 p.m. with the Employee Health/Infection Control registered nurse (RN)-A. RN-A confirmed there were no other infections tracked for 2009 and further reported that the log used in 2009 was ineffective for surveillance and a new system was started in 2010. The surveyor inquired about the new surveillance system in use and RN-A submitted a form titled Patients with Infections that listed 5 patients in 2010 with a diagnosis of wound infection (this form included the following information: patient medical record number, date of birth, admission date, discharge date and type of infection). No other patients or infections were identified for 2010 on this form. RN-A stated this list showed patients with nosocomial infections only. The surveyor inquired about tracking of infections other than those determined to be nosocomial and RN-A reported that a list of infections is received on a monthly basis and this list is reviewed to determine whether the infection is hospital acquired; if hospital acquired then it is listed on the Patients with Infections report. RN-A submitted a report of patients with infectious diagnoses received for April 2010. The report titled urinary tract infection (UTI), Hospital, April 2010, showed 54 patients with this diagnosis. The form did not indicate whether the UTI ' s were catheter-related or hospital acquired and also did not indicate the treatment or effectiveness of the treatment. The report also revealed the following for April 2010 for patients in the hospital setting: 20 patients with a diagnosis of pneumonia, 3 patients with post-op wound infections, 2 patients with hepatitis C, 1 patient with Lyme ' s Disease, and 1 patient with clostridium difficile (C-Diff). Additionally, RN-A received a list of patients seen in the clinic with an infectious diagnosis for April 2010 which showed the following: 44 patients with a UTI diagnosis and 15 patients with pneumonia. The report also included the following information that did not indicate the CAH location: 10 patients with methicillin-resistant Staphylococcus aureus (MRSA), 2 patients with scabies, 2 patients with tuberculosis, 20 patients with post operative complications and 1 patient with Surgical Infection Prevention Knee Arthroplasty Surgery. The surveyor asked RN-A for evidence of analysis of these infections for April 2010 and RN-A could not produce any additional information. RN-A was given additional opportunities to demonstrate the facility surveillance process by randomly selecting patients from lists obtained by RN-A which confirmed an infectious diagnosis or lab result and RN-A again was unable to provide evidence of implementation of the surveillance process.
Review of the facility policy titled Infection Prevention Surveillance (last reviewed/revised 5/20/10) stated, "Infection Prevention surveillance involves the collection, analysis, trending and reporting of the information related to infection in the clinic, hospital and outpatient areas of patients and employees. Types of surveillance include: Facility-wide (and) Target-or focus-based, i.e., information is gathered on a specific procedure." This policy also stated, " A targeted/focus surveillance approach has been chosen to include the following types of infections: Surgical site infections (SSI), primary bloodstream/intravascular device-related infections, pneumonia (medical and/or surgical), (and) urinary tract infections (catheter-related)." A section of the policy titled " Calculating and analyzing surveillance rates " stated, "Surveillance ratios are reported to the Infection Control Committee and to those health care professionals who are most able to impact and improve patient care." Further review of the facility infection control policies and procedures revealed the facility lacked a policy that defined communicable disease; this was verified by RN-A.
The facility tuberculosis risk assessment dated 2009 indicated the facility tuberculosis (TB) policy needed to be updated. RN-A reported this risk assessment was completed in " June or July " of 2009. Review of the facility policy titled Tuberculosis (Management of Suspected Case) dated 6/98 and last revised 3/04, instructed staff regarding the triage of patients in the emergency/OP rooms, listed some guidelines on use of protective masks and showed recommended precautions during ambulance transfer of the patient. The policy book contained a policy titled Tuberculosis Exposure Control Plan that was identified as a draft policy and dated 2/2010; RN-A reported this draft policy had not been forwarded for review or approval as of July 22, 2010.
During the interview with RN-A on 7/22/10, RN-A reported the facility used two step skin testing for employee TB screening. On 7/22/2010, and 7/23/10, employee records were reviewed for tuberculosis screening. Eleven records were reviewed and four employees met the criteria for eligibility of two step testing. Of these four records, all four showed the second skin test of the two step tuberculosis screening was administered outside of the recommended time frame established by CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Facilities www.cdc.gov