HospitalInspections.org

This Standard is NOT MET as evidenced by:

Based on record reviews and interviews with the Infection Control Officer on June 22 to 24, 2010, it was determined that the CAH failed to implement a complete and timely system for identifying, reporting and investigating nosocomial infections of patients and personnel.

Findings include:

1. Review of the Infection Control Committee meeting minutes, the Surgical Committee meeting minutes and the nosocomial infections line-listing for that year 2009 to 2010, revealed inconsistencies in data, resulting in incomplete identification, incomplete data analysis and incomplete reporting of nosocomial infections to medical staff, nursing and administration. This finding was supported during interviews with the Infection Control Officer as she agreed that no aggregate nosocomial surveillance data report existed.

2. Review of the Infection Control Program revealed that there was no consistent process for the departmental environmental surveillance rounds completed by the Infection Control Officer. There was no documentation to support that these rounds were completed on a routine basis. In addition, during an interview with the Infection Control Officer on June 22, 2010, it was revealed that there was no policy or procedure for conducting these rounds.

3. During a tour of the Radiology Department on June 22, 2010, it was observed that products were being used by hospital staff that were not approved by the Infection Control Program, including PDI Sani-Wipe (Green Top) disinfectant and Vaseline hand lotion. An interview conducted with the Infection Control Officer on June 22, 2010 revealed that she was not aware of these products being used in the hospital. In addition, there was no formal policy, procedure or protocols for the approval and use of hospital disinfectants and hand hygiene products.

Based on review of incident reports and interviews with key staff on June 23, 2010, it was determined that the facility failed to include all things related to patient health and safety in the hospital-wide quality assurance program.

Findings include:

1. The policy titled 'Patient Adverse Events Reporting' sated, "4. Quality Services Review Procedures: 1) All events should be reported to the department of Quality Services for evaluation."

2. During a review of incident reports on June 23, 2010, the surveyor did not find any documentation of trending and/or analysis.

3. During an interview with the Manager Case Management and Quality on June 23, 2010, it was confirmed that there was no documentation of trending and analysis of incident reports and therefore no quality information related to incidents was presented to the Quality Committee and/or the Board of trustees.