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Based on review of the infection control documents, hospital meeting minutes, policies, procedures and personnel files, and interviews with staff, the hospital failed to develop an active on-going infection control program for ensuring a sanitary environment, and identifying and preventing infections and communicable diseases by designating a person qualified through training and/or experience as the infection control officer/nurse (ICO).

Findings:

1. On the morning of 09/29/2010, the Director of Nursing, Staff C, stated she was in charge of the infection control program. Review of Quality documents listed Staff G as the "Infection Control Nurse". Review of personnel files, medical staff meeting minutes and governing body meeting minutes did not reflect either staff member had been designated as infection control practitioner/nurse. Neither personnel files contained evidence they had training or experience in infection control. On the afternoon of 09/30/2010, Staff C stated she and Staff G did not have any previous experience in infection control and had not received any infection control training on setting up an infection control program with active surveillance and analysis of data. She stated neither had been designated by the governing body or medical staff as the individual responsible for infection control.

2. The infection control policy manual did not contain an infection control plan for 2010. It did not describe where the infection control program would report findings, analyze data and develop and implement corrective action plans to address problems identified.
Although the policy and procedure manual had been approved by the medical staff and governing body, it did not contain policies and procedures based on current standards.
a. The infectious disease notification to the State Health Department did not contain the current requirements or notification methods.
b. The handwashing policy was not based on CDC (Centers for Disease Control and Prevention) guidelines.
c. The isolation policy was not based on current CDC guidelines.

3. Review of infection control data and meeting minutes for medical staff and quality assurance did not show ongoing analysis of patient infections. The infection control report on infections just listed the infections and if they were nosocomial. The meeting minutes did not demonstrate the data collected for infections had been reviewed, evaluated and analyzed to ensure antibiotic therapy was appropriate. Review of infection control data and meeting minutes where infection control was listed as a topic, did not show the infection control program had been reviewed, evaluated and revised to ensure the program included monitoring of the environment to provide a safe and sanitary environment; and provisions to identify, investigate, report, and prevent the spread of infections and communicable diseases among patients and the staff, including contract staff, physicians and allied health workers and volunteers.

4. Review of infection control data and meeting minutes for medical staff and quality did not contain analysis of employee health data. It did not contain staff and physicians immunization data. On the afternoon of 09/30/2010, Staff C stated staff/employee health and immunization analysis was not part of the infection control program.nine of twelve staff and three of five physician files did not contain complete immunization histories. According to the personnel files, eighteen of eighteen staff had not been offered influenza immunization.

5. Review of infection control data and meeting minutes for medical staff and quality did not contain data from active surveillance of staff or monitoring of staff to ensure recognized aseptic practices were followed. On the afternoon of 09/30/2010, Staff C stated she did not conduct surveillance/observation activities of staff to ensure policies and procedures and standards were followed. She had not inserviced employees on proper handwashing/hand cleansing techniques or performed any hand sanitation surveillance.

Based on record review and interviews with hospital staff the hospital does not ensure that an effective quality assurance program is implemented and evaluates the quality and appropriateness of the diagnosis and treatment of patients in the hospital through a functioning QA program and all patient care services and other services affecting patient health and safety are evaluated and the hospital collects and analyzes data concerning the quality and appropriateness of all patient care furnished in the CAH.


Findings:

1. QA meeting minutes for 2009 and 2010 did not contain evidence of the analysis of data presented to identify problems, evaluate situations, and take corrective actions.

a. Reports from pharmacy just documented Pharmacy 100%. The meeting minutes did not say what was 100%. The QA coordinator said that referred to the reports from the Consultant Pharmacist.

b. Radiology QA reports did not have any evaluations of patient care such as radiation safety or quality of the films

2. Governing Body and Medical Staff meeting minutes for 2009 and 2010 did not contain evidence of any QA analysis of data presented to identify problems, evaluate situations, and take corrective actions.

3. Review of infection control data and meeting minutes for medical staff and quality assurance did not show ongoing analysis of patient infections. The infection control report on infections just listed the infections and if they were nosocomial. The meeting minutes did not demonstrate the data collected for infections had been reviewed, evaluated and analyzed to ensure antibiotic therapy was appropriate. Review of infection control data and meeting minutes where infection control was listed as a topic, did not show the infection control program had been reviewed, evaluated and revised to ensure the program included monitoring of the environment to provide a safe and sanitary environment; and provisions to identify, investigate, report, and prevent the spread of infections and communicable diseases among patients and the staff, including contract staff, physicians and allied health workers and volunteers.

Based on review of the hospital's swing bed policies and procedures and personnel files, and interview with the swing bed coordinator, the hospital failed to designate a qualified individual to direct the hospital's swingbed activity program.

Findings:

1. Staff F stated she was the swingbed coordinator and activity director.

2. Review of Staff F's personnel file did not contain evidence she met the requirements of a qualified activity director.

3. In interviews with the Director of Nursing and Staff F on the morning of 09/29/2010, they stated Staff F had not attended a training course approved by the State.