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Based on observation, staff interview, policy review, and review of records of hospital acquired infections, the facility failed to avoid sources and transmission of infections and communicable diseases.

Findings include:

1. On 03/23/2010 at 11:35 a.m. observations made on the 3rd floor with the Accreditation Coordinator Director present revealed that on the floor outside of each patient's room door was a new sharps container.
When the Accreditation Coordinator Director (ACD) was asked about the sharps containers being a potential contamination issue she stated that the hospital was contracting with a new medical waste company and an outside company was changing out all sharps containers in patient rooms.

2. On 03/23/2010 at 12:30 p.m. observations were made on the LTAC Hospital 2nd floor with the LTAC Director of Clinical Services present. At Room #267 a hospital phlebotomist was observed leaving the patient's room with gloves, mask, isolation gown and a phlebotomist tray. Room #267 had a sign on the door which stated that the patient was on Droplet and Contact Precautions. The phlebotomist placed the tray outside the patient's door on the floor by the wall. The mask, gloves and gown were removed then rolled up and placed on the phlebotomist tray. The phlebotomist then picked up the tray and preceded to walk down the hall. LTAC Director of Clinical Services interrupted the phlebotomist for disposal of the isolation attire. When the phlebotomist was asked why she placed the isolation attire on the phlebotomist tray she stated that there was no place in the room to leave it. LTAC Director of Clinical Services stated that the isolation attire should have been left in the patient's room.

3. Review of the hospital's Infection Control Standard and Transmission-Based Precautions procedure revealed, "Personal Protective Equipment (PPE) will be donned (applied) before entering the room and will be doffed (removed) prior to leaving the room."

4. On 03/23/2010, at 1:40 p.m. interview with the Infection Control Nurse revealed that employees in all clinical areas of the hospital were inserviced on the Isolation Precautions and use of PPE. There was documented evidence that the phlebotomist, observed at 12:30 p.m., had attended the hospital Infection Control Standard and Transmission-Based Precautions inservice on 03/17/2009.

5. Review of the hospital's "Hospital Associated Infections" (HAI) log from August 2009 through December 2009 revealed:
August 2009 eight (8)
September 2009 five (5)
October 2009 five (5)
November 2009 three (3)
December 2009 seven (7)

6. Review of the Hospital Utility Systems air quality test and balance reports for the isolation rooms revealed no documented evidence of parameters, pass/fail scores or ranges.

Review of the hospital's Utility Systems EC.7.10.16 Policy on Installing and Maintaining Appropriate Pressure Relationships revealed, "It is the policy of the (the hospital) that all ventilation systems shall be installed and maintained in a manner that will ensure that the appropriate pressure relationship, air exchange rates, and filter efficiencies for ventilation systems that serve areas specially designed to control contaminants." The policy's effective date was 03/01/2005. There were no documented parameters, pass/fail scores or ranges in the policy. The Infection Control Nurse was also unable to find any documented parameters, pass/fail scores or ranges present in the policies or forms.