HospitalInspections.org

Based on record review and interview, the facility failed to develop a system that identified, investigated, and reported infections and communicable diseases for inpatients and all personnel, including agency nurses, housekeeping staff and volunteers, in a timely manner. Findings include:

In-patient Logs from 01/2015 through 08/2015 showed the facility treated the following numbers of in-patients with antibiotics:

Jan = 13
Feb = 15
March = 18
April = 10
May = 17
June = 5
July = 3
Aug = 12

The information reflected in the gathered data did not consistently differentiate or identify nosocomial vs non-nosocomial infections, asymptomatic and symptomatic infections, infection sites, bacterial susceptibility to antibiotics, treatments or outcomes.

A review of the facility infection control policy and procedures showed multiple recommendations and work restrictions for personnel with infectious diseases. However, no tracking or trending of employee illnesses was conducted. And, no monitoring of employee adherence to the recommendations for employee health, as it related to infection control, was conducted.

During an interview on 9/17/15 at 8:55 a.m., staff member E, infection control officer, said the data for patients being administered antibiotics did not reflect what the antibiotic was being used to address, site of infections, symptoms, or the outcome of the treatments. This information would be available in each patient's clinical chart. Staff member E said she did not receive data for employee illnesses, unless the infection was something that was reportable to the state.

Based on interview and record review, the facility failed to use the correct consent form for 4 (#s 13, 18, 19, and 20) of 20 sampled patients. Findings include:

1. Patient #13 was admitted to the facility on 3/11/15 with the diagnoses of malaise and prostate cancer. He was admitted as in-patient status.

Review of Patient #13's chart showed that it was missing the consent form used for in-patients.

2. Patient #18 wad admitted to the facility on 3/4/15 with the diagnosis of altered mental status. She was admitted as in-patient status.

Review of Patient #18's chart showed an out-patient consent form was signed. There was no consent signed for the in-patient status.

3. Patient #19 was admitted to the facility on 12/25/14 with a diagnosis of bilateral pneumonia. She was admitted as in-patient.

Review of Patient #19's chart showed an out-patient consent form was signed. There was no consent signed for the in-patient status.

4. Patient #20 was admitted to the facility on 9/6/14 with the diagnoses of congestive heart failure, and diabetes. She was admitted to a swing-bed.

Review of Patient #20's chart showed an out-patient consent form was signed. There was no consent signed for the swing-bed status. (The same form used for in-patient status.)

During an interview on 9/16/15 at 4:10 p.m., staff member C, NAC, stated when a patient goes in as an in-patient or a swing- bed patient, she sets up the admission consent form for the patients to sign. All of the patients seem to start out with the out-patient consent form.

During an interview on 9/17/15 at 8:52 a.m., staff member D, NAC, stated we have a check sheet to make sure we are using the correct consent form. The check sheet was just put together last week. What might happen is a night nurse, after the NAC goes home, pulls up the out-patient consent form. This is then signed by the in-patient or swing-bed status patient.

Review of the facility's consent form for out-patient services and admission consent form had differences.