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Based on interview and record review, the facility failed to develop and maintain an active hospital wide Infection Control Program for the prevention, control and investigation of infections. Resulting in the increased potential for increased risks of infections for all patients treated in the facility.

See specific A tag:

A-0748. Failure to ensure the Infection Control Officer received specialized training in infection control training.
A-0749- Failure to monitor and implement isolation precautions consistently.

Based on interview and record review, the facility failed to follow their policy to ensure that their infection control officer received specialized training in infection control, resulting in the increased potential for unidentified infections and/or the increased potential for the transmission of infections for all patient's in the facility. Findings include:

On 01/23/17 at approximately 1500, an interview and review of the infection control program was conducted with the Infection Control Officer (ICO) (Staff M). The Director of Nursing (DON) and the Quality Consultant Staff (K) were present for the interview. Staff M explained she was a Registered Nurse (RN). She had been in her role as the (ICO) since November 2016 and her responsibilities included Nursing Education and the Infection Control Program. When asked if she had received any training in infection control Staff M stated, "No." When asked if there was an infection control committee she stated, "No. I'm a one person department."

On 01/24/17 at 1300 a review of the facility's Infection Control Plan 2016 policy dated 01/02/2015 documented the following:
Scope of Services/Processes/ Structures:
"...The hospital has identified an Infection Control Practitioner as the individual with clinical authority over the infection prevention and infection control program is a registered nurse who has completed the foundations program through the Michigan Society of Infection Prevention and Control (MSIPC) and completes yearly continuing education opportunities directly related to infection prevention..."

Based on observation, interview and record review, the facility failed to (1) maintain and follow their infection control program policies for surveillance, prevention and control of infections and (2) consistently implement isolation precautions for one (#7) supplemental sampled patient reviewed for infection control, resulting in the potential of the transmission of infections for all patients treated in the facility.

Findings include:
On 1/23/17 at approximately 1215 a tour of the 5th floor medical surgical unit was conducted with Nurse Manager Staff I. Staff I was observed as she attempted to entered an Isolation room for patient #7 in response to a call light. There was no signage posted that would have prompted facility staff or visitors to 'see the nurse' prior to entering the room to ensure appropriate personal protective equipment (PPE) was applied and required protocols were performed.

At that Staff I was queried regarding what type of precautions were in progress for patient #7. Staff I stated, "The patient is on droplet precautions." When further queried regarding the patient's condition regarding the precautions Staff I stated, "I'm not sure. The patient's nurse would be able to answer that question." When asked to explain why there was no signage postage to 'see the nurse' regarding isolation precautions and protocol Staff I stated, "There should be."

On 1/23/17 at approximately 1500 an interview and review of the infection control program was conducted with the Infection Control Officer Staff M. The Director of Nursing (DON) was present for the interview. Infection Control logs and minute meetings were requested for review. Staff M explained she had been in her role as the Infection Control nurse since November 2016. Staff M stated, "When I come on in November there were things everywhere. I had to organize things. I threw things out. I needed to start from November going forward. I had to prioritize. I'm caught up on Nurse competencies. I'm caught up on immunizations."

At that time Staff M provided the surveyor with 2 logs that were conducted on the 5 North (Medical-Surgical) nursing unit dated 11/2016 and 12/2016 for handwashing observations and storage of equipment. There were no logs provided for the 3rd floor (Traumatic Brain Injury) nursing unit or the 4th floor (Behavioral Health) nursing unit. Staff M explained she was the only one who performed audits. She stated, "I will be doing all units for January."

Staff M was asked how she monitored and collected data to prevent the spread of infections in the facility. Staff M explained she was on the nursing units daily and they (facility staff) huddled regarding infection control concerns. However, Staff M was unable to provide documentation of minute meeting notes or analysis of infection control surveillance activities.

When further queried Staff M explained that when she attended the facility's Quality Assurance (QA) meetings she was not required to report off on any infection control findings. She stated, "I'm not always selected to report data analysis at those meetings." When asked to provide further data collection or analysis of the aforementioned staff huddles, Staff M stated, "I don't have anything else. We would discuss things. I didn't necessarily take or keep notes."

Staff M was further queried regarding her role in the most recent closure of the cafeteria due to water damage and how it impacted the dietary department including meal service, sanitation, drinking water, Staff M stated, "I'm not involved." When asked to explain who would be responsible for ensuring dietary staff were performing precautions to prevent the spread of infections in light of how meals were being prepared, served, and sanitized, Staff M confirmed she should have a more active role in those processes.

Staff M was asked if there were any patients on isolation precautions currently. Staff M explained that there were no patients on isolation precautions to her knowledge. Staff M stated, "I was here on Friday (1/20/17) I don't recall any one being in isolation then.

The DON was overheard at 1535 on 1/23/17 and he explained patient #7 was on isolation precautions. When asked to explain why there was no signage posted for facility staff or visitors to 'see the nurse' prior to entering the patient's room, the DON explained that everyone would know isolation precautions were in place because the patient was in an isolation room and that would have been sufficient. When further queried the DON was unable to explain why the patient was in an isolation room. When asked to explain what type of PPE was required for those isolation precautions the DON said a mask.

On 1/23/17 at 1700 a review of the electronic medical record for patient #7 was conducted with the DON.
According to the admission registration record sheet, patient #7 was a 52 year old female admitted to the facility on 01/18/17 with a diagnosis of a sinus infection. According to the History and Physical dated 1/18/17 the patient had a diagnosis of leukopenia. Physician orders included neutropenic precautions (measures to prevent infections), on 01/18/17 for a white blood cell count of 1.6 (normal range 4,000-11,000 per cubic millimeter).

At that time, when further queried the DON explained the patient would have been on isolation precautions to protect her from infections. The DON confirmed a sign to see the nurse should have been posted on the patient's door for facility staff and visitors prior to entering the patient's room. When asked if droplet precautions were the same as neutropenic precautions the DON stated, "No. Those (neutropenic) precautions would be more involved to protect the patient." However, the DON offered no further specific precautions at that time.

On 1/23/17 at 1720 a review of the facility's Standard Precautions Policy dated 9/12/12 documented the following:
"2. Patient Placement... Patients susceptible to infections due to decreased immune responses such as severe leukopenia may benefit from placement in a private room.

On 1/24/17 at 1300 a review of the facility's Infection Control Plan 2016 policy dated 01/02/2015 documented the following:
The Infection Surveillance, Prevention and Control Program:
Surveillance Methodology:

"The Infection Control Department screens all microbiology reports to determine whether culture reports warrant investigation, monthly reporting of contagious diseases to appropriate health department. Notification of transferring facilities of significant organisms...devices related infections reported monthly according to CDC National HealthCare Safety Network (NHSN) guidelines.

Performance Improvement Surveillance monitors are chosen to reflect how the hospital can increase the quality of healthcare through the practice and management of infection control. The monthly overall healthcare infection rate is reported to the Quality Director, who then reports to the Board of Directors and the Medical Executive Committee.

Health Care Acquired Infection Data is collected by the Infection Control Coordinator and evaluated monthly. Surveillance reports, analysis, action taken, and follow up are documented in the committees minutes..."