HospitalInspections.org

Based on interview and record review, the facility failed to ensure the quality program documented monitoring and follow up when new actions were put in place. This failure had the potential for ineffective actions or programs to not be identified or tracked at an organizational level.

Findings:

During an interview with the quality nurse (QN) on 9/13/18 at 1 pm, she described an area of infection control that had been identified by the quality committee as needing improvement. QN stated that the housekeepers did not have formalized training and follow-up with the infection control nurse. QN stated that the infection control nurse had begun a series of staff education, in-services, and other activities to ensure the housekeeping staff were using best practices for infection control. QN stated the follow up for the measures taken had been informal, one-to-one conversations with the infection control nurse and that no documentation had occurred. QN confirmed the quality process required written follow up.