HospitalInspections.org

Based on review of records and interview with staff, the facility failed to ensure methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings as documented in 1 (Policy ID 13092753 Infection Prevention & Control Program) of 4 reviewed Infection Control policies was implemented.

Review of Policy ID 13092753 Infection Prevention & Control Program, Last Approved 04/2024, revealed the following on page 3 of 21:

"Risk Assessment and Prioritization of Goals

The infection control team identifies risks for transmitting and acquiring infections agents throughout the hospital based on many factors. The infection control team will develop a risk assessment at least annually or whenever significant changes occur in the factors noted below using information from all applicable committees and individuals as appropriate. ... At least annually the Infection Control Committee will review the risk assessment and develop action plans to address issues. These assessments and plans are shared with nursing administration."

Review of the Risk Assessment for Infection Surveillance, Prevention and Control Programs in Ambulatory Healthcare Settings showed that it was for 2023 and dated 12/15/23.

Review of the Titus Regional Medical Center Infection Prevention & Control Plan Review - 2024 revealed that this plan had become effective January 1, 2024.

Interview with Staff #2, Chief Nursing Officer, and Staff #14, Senior Director of Quality confirmed that these were the most recent approved documents and that an assessment and plan for 2025 had not been accomplished per the Infection Prevention & Control Program policy.