HospitalInspections.org

Based on record review and staff interview the Critical Access Hospital (CAH) failed to follow their infection control program and develop policies and procedures to assure they identified, reported, investigated, and controlled infections.

Findings included:

- Review of the medical record on 2/9/10 for patient #1 revealed the patient was admitted on 12/9/09 for an outpatient surgical procedure with a preoperative diagnosis of an infected cesarean (c-) section wound with a positive culture for Methicillin Resistant Staph Aureus (MRSA - an infection-causing bacteria resistant to almost all antibiotics).

Review of the CAH's infection control log dated 12/6/09 to 12/31/09 lacked evidence the patient was identified as having an infection.

- Review of the medical record on 2/8/10 for patient #8 revealed the patient was admitted on 8/20/09 with an diagnosis of an infection to a sternum (chest) incision. The admission lab orders revealed two blood cultures were ordered for probable staph infection the same day of admission. The physician ordered "Vancomycin 900 IV (Intravenous) today". The laboratory preliminary report on 8/22/09 was a positive staphylococcus aureus wound infection.

Review of the CAH's infection control log dated 7/28/09 to 8/31/09 lacked evidence the patient was identified as having an infection.

Review of the CAH Infection Control Program, with a revised date of 8/10/2005, states under "Methods of Surveillance, Purpose: Identifying Nosocomial infections and evaluating the current isolation policies and practices...I. Reporting, A. Med Staff, Quarterly, Safety Committee, Monthly, 1, Number of patients admitted with infectious diseases...Invasive procedures..." Review of the CAH's infection control policies and procedures failed to find a procedure for maintaining the log, reporting, investigating, and identifying infections. Review of the Medical Staff and Safety Committee meeting minutes on 2/10/10 lacked evidence the infection control officer reported infectious or nosocomials diseases.

Interview with staff A on 2/10/10 acknowledged patient #1 and #8 failed to be identified as patients with infections. Staff A confirmed the CAH failed to develop policies and procedures specific to reporting, identifying, and investigating infections.

- Based on observation and staff interview the Critical Access Hospital (CAH) failed to use disinfectants in accordance with the manufactures instructions.

Findings included:

- Review of the CAH's cleaning product "RE-JUV-NAL, One Step Disinfectant Germicidal Detergent and Deodorant", product information revealed a contact time for "HIV-1 (AIDS virus) is inactivated after a contact time of 4 minutes...H (hepatitis)BV(virus) and HCV is inactivated after a 10 minute contact time. Use a 10-minute contact time for all other viruses, fungi, and bacteria listed...Staphylococcus Aureus...Community associated Methicillin Resistant Staphylococcus Aureus..."

- Observation of housekeeping staff B on 2/8/10 at 10:20am terminally cleaning the room known as the hospice room revealed they used RE-JUV-NAL #16 disinfectant. Observation revealed they applied the solution with a wet microfiber cloth and allowed the solution to dry. Observation of the disinfectant wet contact time revealed the solution dried within a 5minute time.

Interview with staff B on 2/11/10 acknowledged they were unaware of the manufactures 10-minute contact time to kill viruses and bacteria.

- Observation of surgical staff on 2/10/10 cleaning the operating room (OR) after a laparoscopic procedure revealed staff sprayed RE-JUV-NAL #16 disinfectant on the surface of the roller bed and OR table and wiped it off within four minutes of the initial application.

Interview with staff C and D acknowledged they were unaware of the manufactures 10-minute contact time required to kill viruses and bacteria. Interview with staff A confirmed the CAH failed to follow the manufactures instructions for the disinfectants use.

Based on record review and staff interview the Critical Access Hospital (CAH) failed to assure the providers authenticated all entries in the medical record with the dates and times for 7 of 20 patient records reviewed. (#'s 1, 4, 8, 12, 14, 15, and 17)

Findings included:

- Review of the medical record on 2/9/10 for patient #1 revealed the admission orders dated 8/16/09 lacked the time the physician signed the orders. The history and physical lacked the date and time the physician signed the document. The discharge summary lacked the date and time the physician signed it.

- Review of the medical record on 2/8/10 for patient #4 with an admission date of 1/14/10 revealed nine phone or verbal orders written between the dates of 1/19/10 and 2/1/10 lacked either the date, time or physician signature.

- Record review of the medical record on 2/9/10 for patient #8 revealed the admission orders dated 8/20/09 lacked the time the physician signed the orders. The history and physical lacked the date and time the physician signed the document. The discharge summary lacked the date and time the physician signed it.

- Record review of the medical record on 2/10/10 for patient #12 revealed the phone order taken for the admission order dated 11/10/09 lacked the time the order was written, the signature of the nursing personal who wrote the order, and the date the physician signed it. The history and physical and discharge summary lacked the dates and times the physician signed them. One physician order written on 11/16/09 lacked the time the physician signed the order.

Interview with staff E on 2/10/10 at approximately 11:30am confirmed the documents lacked the date and/or time the physician signed the documents. Document review of the Medical Staff Bylaws, under "Medical Record, I." revealed the physicians are not instructed to time all entries in the medical record.

This deficient practice also affected record #'s 14, 15 and 17.