HospitalInspections.org

Unable to assess compliance due to on-going construction/renovation.

Unable to assess compliance due to on-going construction/renovation.

Unable to assess compliance due to on-going construction/renovation.

Unable to assess compliance due to on-going construction/renovation.

At the time of the revisit on 10/02/14, this deficiency was not corrected.
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Based on review of hospital documents, policies and procedures and meeting minutes, surveyors' observations and interviews with staff, the hospital failed to:

a. Develop and maintain an active on-going infection control/infection prevention (IC) program for ensuring a sanitary environment, and identifying and preventing infections and communicable diseases among patients and staff;

b. Analyze IP surveillance data and concerns, develop corrective actions when needed and conduct follow-up to ensure corrective actions are appropriate and sustained to ensure a sanitary environment and avoid sources and transmission of infections for patients and personnel; and

Findings:

1. The facility failed to develop a written infection control plan with details of:
a. When and and where the business of infection control committee would occur; and
b. How often the infection control program would conduct surveillance/monitoring to ensure all departments complied with infection control policies and standards of practice for infection control.

2. The hand washing policy did not contain information that use of hand sanitizers was not effective against Clostridium difficile and use of soap and water must be utilized instead.

3. Meeting minutes did not reflect all surveillance/monitoring and concerns were:
a. Reviewed,
b. Analyzed, and
c. Corrective actions identified with
d. Follow-up to ensure corrective actions were effective and maintained.

Unable to assess compliance due to on-going construction/renovation.