HospitalInspections.org

The Hospital reported a census of 19 patients. Based on observation, document review and staff interview the Governing Body failed to ensure the hospital's environment remained clean and safe for patients, visitors and staff. The Governing Body failed to provide oversight to the Quality Assessment and Performance Improvement Program which failed to address an unidentified black substance observed throughout the hospital and basic cleanliness in patient care areas, service area, food preparation areas, and outpatient areas. The Governing Body failed to ensure the hospital and hospital staff developed and implemented an effective Infection Control Program. The failure to effectively govern the hospital to ensure healthcare workers followed infection control standards of care to avoid the potential transmission of infections and communicable diseases placed all patients, visitors and staff at risk for healthcare associated infections.

Findings include:

- The Governing Body failed to assure the Hospital had an effective Quality Assessment and Performance Improvement Program to monitor the services offered at the Hospital as required at CFR 482.21, A-0263.

- The Governing Body failed to assure the Hospital maintained a clean, sanitary environment to protect the safety of patients, visitors and staff as required at CFR 482.41, A-700.

- The Governing Body failed to assure the Hospital's effectiveness of the Infection Control Program as required at CFR 482.42, A-0747.

Based on observation, staff interview and document review the Hospital failed to establish an effective and ongoing Quality Assessment Performance Improvement (QAPI) program to monitor the services and departments at the Hospital. Non-compliance with this requirement has the potential to adversely affect all patients at the Hospital.

Findings include:

- The Hospital failed to establish an effective and ongoing Quality Assessment Performance program to monitor the services and departments at the hospital that included an unidentified black substance and dirt observed throughout the hospital. The hospital failed to follow the minimal plan developed by their QAPI committee. See further evidence at CR 482.21(a)(2), A-0267.

Based on observation, staff interview and document review the Hospital failed to establish an effective and ongoing Quality Assessment Performance Improvement (QAPI) program to monitor the services and departments at the Hospital that included an unidentified black substance and dirt observed throughout the hospital. The hospital failed to follow the minimal plan developed by their QAPI committee. Non-compliance with this requirement has the potential to adversely affect all patients at the Hospital.

Findings include:

- The Hospital's Quality Assessment and Performance Improvement Plan reviewed on 11/3/10 dated 8/10 revealed the Board of Trustees designated the Quality Assessment and Process Improvement Committee to include all departments in the development and monitoring of quality indicators to improve the hospital's practices.

- The hospital provided reports on 11/2/10 which identified areas of mold on 9/23/08, 2/19/10, and 5/21/10. The QAPI plan reviewed on 11/3/10 lacked a plan for environmental monitoring for mold. Based on the history of mold and current areas identified with mold the QAPI plan should include indicators related to mold identification, remediation and prevention. The failure to include current indicators based on the finding of mold placed all patients, visitors and staff at risk for health acquired infections.

See evidence of an unidentified black substance throughout the hospital cited at CFR 482.41(a), tag A 0701; CFR 482.42(a)(1), tag A 0749, and CFR 482.42(b), tag A 0756

- The QAPI project for nursing reviewed on 11/3/10 revealed the nursing department tracked three items; call light response times, heart failure and compliance with pneumonia protocol/ measures.

Infection Control Staff D on 11/3/10 at 9:00am reported one of the hospital protocols to prevent transmission of respiratory infection for pneumonia patients included placing the patient in droplet isolation until the cause of the infection was identified by laboratory results.

Nursing staff failed to follow the protocol/measures including isolation precautions developed by the hospital for sampled patients # 2 and 14 diagnosed with pneumonia. The QAPI process failed to identify staff failed to follow established pneumonia protocols to prevent the potential transmission of respiratory infection.

- Patient #2 ' s medical record reviewed on 11/2/10 at 10:30am with Administrative staff B, revealed the hospital admitted the patient on 11/1/10 diagnosed with lower left lobe pneumonia (a respiratory infection). Staff failed to place the patient in droplet isolation. The patient walked the hallway of the medical surgical unit on 11/2/10 at 9:45am with a family member.

Observation of patient #2's room on 11/2/10 at 11:00am revealed staff failed to place the patient in isolation. The room door lacked the required isolation sign. The room lacked the required gowns, gloves and masks/PPE (personal protective equipment) for visitor and staff protection. Administrative staff B and F on 11/2/10 at 11:0oam stated, " We implement isolation precautions by nursing judgment ". Administrative staff B and F acknowledged hospital staff failed to initiate isolation precautions for the pneumonia patient. Staff F stated on 11/2/10 patient #2 would be placed in isolation to prevent the potential spread of respiratory infection.

The failure of QAPI to ensure all staff followed protocol/measures established for pneumonia patients placed all patients, visitors, and staff at risk for respiratory infection.

- Patient #14 ' s closed medical record reviewed on 11/3/10 revealed the hospital admitted the patient on 8/29/10 diagnosed with bronchopneumonia to rule out MRSA (Methicillin-resistant Staphylococcus aureus). Laboratory results of a sputum culture dated 9/1/10 identified a" large number of staph aurous growth" and required antibiotics medication to treat the infection. The closed record (including the plan of care) lacked evidence staff placed patient #14 in isolation (to prevent the spread of a respiratory infection that requires droplet isolation).

Infection Control Staff D on 11/3/10 at 9:00am reviewed patient #14 ' s medical record and acknowledged the record lacked evidence staff followed established measures/protocols to prevent the spread of infection. The QAPI process failed to identify hospital staff followed protocol/measures to prevent the potential spread of respiratory infections

- QAPI information for Infection Control reviewed on 11/3/10 identified infection control staff monitored and tracked hospital staff ' s hand hygiene/washing compliance. See evidence of staff ' s failure to follow acceptable standards of practice and hospital policy with hand hygiene and hand washing cited at CFR 482.42(a)(1), A 0749.

The hospital reported an average daily census of 13 with 49 certified beds. Based on observation, document review and staff interview the Hospital failed to implement and monitor the effectiveness of the maintenance and housekeeping staff to assure a clean, sanitary and safe hospital environment for patients, staff and visitors.

Findings include:

- The Hospital failed to provide a maintained, clean, and sanitary environment to protect the health and safety of patients as cited at CFR 482.41(a), A-701.

Based on observation, document review and staff interview the Hospital failed to implement an effective system to maintain a clean and sanitary environment for five-birthing rooms, one-nursery, two-operation rooms and two-procedure room in surgery, two-trauma bays and two-treatment rooms in the emergency departments, all 49 patient care rooms on the medical-surgical unit and outpatient unit and three-intensive care rooms. The hospital failed to maintain the physical therapy, laboratory, pharmacy and dietary departments in a clean and safe manner.

The physical conditions of the hospital and the hospital ' s environment placed all patients, visitors and staff at risk for hospital acquired infections.

Findings include:

- Observation on 11/1/10 between 12:18pm to 4:30pm in birthing room #5 revealed a buildup of unidentified black substance on the wall and the panel that contained oxygen and patient call light controls. The buildup of black substance extended one to two inches above and below the wall unit. The vinyl wall paper border contained an unidentified black substance under the rolled edges.

Maintenance staff M on 11/1/10 at 4:47pm acknowledged the Hospital had problems with humidity. Staff M put on a mask and gloves to spry the wall area in birthing room #5 with a disinfectant, fungistatic cleaner. Staff M removed a seven foot section of wall paper which exposed spots of unidentified black substance on the wall paper and the wall. Staff M reported the spots look like "mold ".

Administrative staff A, B, C, D and Maintenance staff M on 11/1/10 at 5:20pm discussed the wall in the birthing room. Administrative staff D reported the hospital had prior "mold problems" at the beginning of this year.

Infection Control Officer D stated the hospital's medical record room had " mold " on 1/18/10 and the hospital took samples of carpet tape and sent them to an outside laboratory for analysis.

Staff A provided the "mold report" for review on 11/2/10 at 12:00pm. The document revealed the Hospital had two separate incidents with mold, one dated 9/23/08 and a more recent reported dated 5/21/10.

Review of the laboratory report dated 2/19/10 revealed the laboratory found the following types of mold growing on the sample: Penicillium species mold, hormonema dematioides mold and rhodotorula species yeast.

Infection Control, Quality Assessment and Performance Improvement Program and maintenance documentation reviewed on 11/3/10 revealed the hospital lacked evidence of on-going environmental monitoring, evaluation, or preventative measures for mold growth.

- Obstetrical (OB) manager E on 11/1/10 at 12:30pm reported all of the birthing rooms were clean and ready for patient use. Observation of the OB unit on 11/1/10 at 12:30pm revealed similar environmental problems and all lacked cleaning or maintenance of equipment as follows:

Five of five rooms had beds that converted to birthing tables. The tables had leg extensions with a pivot point. The pivot points had a dark red crusty build-up around the entire one inch pipe.

Housekeeping staff GG observed on 11/1/10 at 4:30pm cleaned the pivot point of the birthing bed. Staff GG sprayed the area with Quatanairy cleaner (a disinfectant cleaner) and scrubbed the excess cleaner. Staff GG pinked up the bottle of cleaning spray with the contaminated gloves and reapplied the spray to the pivot point again. During the cleaning of the birthing bed Maintenance staff M entered the room to examine the wall and moved the bed.

The floor contained a one foot wide circle of pooled cleaner with a pink center and dark red outer ring on the floor around the wheel of the bed. Infection control staff D interviewed on 11/1/10 at 4:30pm reported the pool appeared to be blood that dripped down the legs of the birthing bed. Infection Control Staff D acknowledged the beds in the birthing rooms were not completely cleaned and disinfected between patients.

Administrative staff B and Infection Control Staff D on 11/1/10 at 4:45pm reported the hospital's spray cleaner required a 10-minute wet contact time to kill germs. Both agreed cleaning staff should change gloves between dirty tasks and additional cleaning tasks.

Five of five birthing rooms had metal cabinets with sinks. The metal shelves under the sinks were observed with bubbled paint and rust particles. The shower curtain rods in each of the five showers contained rust and a build-up dirt residue around the baseboards that extended three inches into the room. Behind each toilet stool was a gross build-up of dirt and grime.

The shower curtain in birthing room five ' s shower contained a dark orange streak of build-up grime/rust the length of the curtain that extended up one inch from the bottom.

Tour with Obstetrical manager E on 11/1/10 at 12:18pm in the baby nursery revealed two baby warmers. The ceiling above and between the baby warmers contained a five inch wide spider web with dark non-moving specs.

The heating unit in the nursery contained five rusty areas ranging from one to five inches. The floor in front of the heating unit contained a three inch by 12 foot rusted area and the floor had a dirt film extending from the walls.

- Observations in the surgical department with department manager I on 11/2/10 at 4:15pm revealed the following environmental and infection control concerns:

The doors to the two operation rooms and two procedure rooms had deep gouges and rough surfaces, the rooms had multiple cardboard boxes adjacent to patient treatment areas and bare pieces of paper that created an uncleanable surface. The rooms in the surgical department contained multiple ceiling vents covered with a 30 to 50% dust build-up. Stainless steel wall plates contained rust on the surfaces, arm boards ready for patient use were observed with extensive tape residue. All surgical room equipment contained a build-up of dirt film on all the equipment wheels and surgical table legs. The surgical department had a build-up of dirt film around all the wall surfaces.

Surgical manager I on 11/2/10 at 4:15pm reported one designated housekeeper cleaned the surgical department every night and acknowledged the department needed a " deep clean " .

Surgical manager I on 11/2/10 at 4:15pm reported the surgical staff used " Santi Cloth Plus " to clean between patients. Review of the container label revealed the manufacture required a full 10-minute wet contact time.

Surgical manager I on 11/2/10 at 4:15pm demonstrated the use of the disinfectant " Sant-i Cloth Plus" wipes and removed a towelette. Staff I wiped the surface of the surgical table mattress which dried in one minute and 50 seconds. Staff I reported they did not reapply the cleaner. Surgical manager I was unaware of the manufactures requirement to keep the surface being cleaned/disinfected wet with the solution for 10 minutes to kill the germs. Staff I indicated they had not read the instructions on the container or received in-service or education on the use of the chemical disinfectant used to disinfect surface areas and equipment in the surgical rooms.

Procedure room #3 had an 8 inch by 11 inch square hole in the wall behind a round clock. Staff I stated the maintenance staff were aware of the hole in the wall behind the clock, but could not remember when or how it occurred.

- The Physical Therapy department observed on 11/2/10 at 9:00am four bays with therapy mats and padded tables used for patient therapy. Administrative staff P at 9:05am reported the department did not keep any cleaners or disinfectants in the department because staff " only cleaned the therapy surfaces if a patient ' s skin touched the surface."
Without disinfectants available in the physical therapy department staff failed to follow acceptable standard of practice to disinfect all surfaces between patients.

Administrative staff B interviewed on 11/2/10 gave conflicting information about cleaning surfaces in the therapy department. Staff B indicated therapy staffs were required to clean environmental surfaces between each patient and directed staff P to obtain disinfectant and clean all the departments' therapy surfaces.

- The Emergency Department observed on 11/2/10 at 9:45am contained a Trauma Bay with three ceiling vents that contained a buildup of unidentified black substance. Administrative staff A on 11/2/10 at 9:47am stated "Yeah that looks like mold".

The walls in trauma bay one had multiple dark dried crusty streaks. Both adult and pediatric emergency carts and the exam light suspended from the ceiling had drops of dark dried substance. Administrative staff A on 11/2/10 at 9:50am indicated the dark areas appeared to be dried blood.

A procedure room on 11/2/10 at 9:35pm in the Emergency department contained several dark streaks on the front of a cabinet. Department manager H pulled out a "Santi Cloth Plus" toilette with their bare hand and proceeded to clean the area. Staff H walked over to the patient care cart and picked up clean linen to prepare for the next patient without washing their hands or applying gloves. Staff H acknowledged they should have used gloves and washed their hands between cleaning a potential blood spill and handling clean linens.

- Observations in the laboratory on 11/2/10 at 11:00am with administrative staff B and Laboratory staff L revealed the following:

The cabinet next to the blood bank area had dried blood spots, and a 0.1cm wide and 3inch long dried blood streak. Administrative staff B stated the staff should clean blood spills as they happen.

The microbiology room sink had a damaged laminate counter top that measured 3 inches the 8-inches around the sink. The wall above the counter used for micro analysis of samples had three 3 feet by 8 inch areas of peeling paint. These damaged surfaces were uncleanable and needed to be replaced.

- Observation in the pharmacy on 11/2/10 at 11:20am revealed a fridge with four sliding glass doors with a dark fuzzy build-up around the window casing and ceiling vents with dust covering 40% of the surface.

- Observation in the dietary department on 11/2/10 at 1:00pm revealed tape over the dishwasher rinse gauges making it difficult to read. Dietary staff J reported the dishwasher gauge broke several times since installation. A repair man was scheduled for the next day.

Review of hospital dishwashing policy on 11/2/10 at 1:15pm revealed the rinse water temperature should be 180 degrees Fahrenheit to sanitize dishes. The manufacture ' s sticker observed on the side of the machine also noted the water temperature should reach 180 degrees.

Staff J interviewed on 11/2/10 revealed they were unaware of the hospital ' s policy for the water to reach a temperature of 180 degrees Fahrenheit. Staff J reported a temperature of 160 degrees was the standard the staff used.

Dishwasher service repair staff BB interviewed on 11/3/10 at 9:00am reported the unit only needed a temperature of 160 degrees to sanitize. Staff BB could not provide the manufactures information that stated the appropriate temperature.

Quality assurance staff A, Infection Control staff D and administrative staff C on 11/3/10 at 9:15am reported they lacked knowledge of the problems with the dishwasher ' s temperature gauge. Administrative staff were unaware dietary staff deviated from the dishwasher manufacture recommendation for heat sanitizing during the rinse cycle.

Observation in the dry food storage area revealed a dark, unknown substance that extended 12 inches from the floor and covered 9 feet of the wall adjacent from stored food. Maintenance staff M interviewed on 11/3/10 at 11:00am reported they were unaware of the wall area. Upon observation of the area maintenance staff M reported it " looked like mold from the condensation from the cooling unit on the opposite side of the wall. "

Quality assurance staff A, Infection Control staff D and administrative staff C on 11/2/10 at 4:00am reported they were unaware of the dirty environment and staff ' s lack of knowledge for use of disinfectants, cleaning products, and equipment and indicated administration would have a staff meeting that night and clean all the areas.

Interview with staff R on 11/3/10 at 10:00am reported the housekeeping staff lacked evidence of training for the use of cleaning supplies and competencies for the cleaning duties assigned. Staff R reported staff left the Hospital around 1:00am on 11/3/10 after " cleaning all night".

Administrative staff C on 11/3/10 at 9:30am reported they were appalled at the condition of the hospital and the lack of cleaning and maintenance.

The hospital reported an average daily census of 13 with 49 certified beds. Based on observation, document review and staff interview the hospital failed to implement and maintain an active, hospital wide program for the prevention, control and investigation of infections and communicable diseases. The hospital failed to ensure healthcare workers followed infection control standards of care and hospital policy for isolation procedures, hand hygiene, equipment and surface cleaning to avoid the potential transmission of infections and communicable diseases which placed all patients, visitors, and staff at risk for heathcare-associated infections.

The failure to identify and treat, and/or clean the widespread presence of an unidentified black substance on environmental surfaces in patient care areas and the hospital's lack of knowledge about hospital staff's failure to follow isolation policies and infection control practices placed patients, visitors and staff at risk for exposure to potentially infectious microorganism and hospital acquired infections.

Findings include:

- The Hospital ' s infection control officer failed to develop and implement an effective program to identify, report, investigate and take corrective action on black substances identified on 9/23/08, 5/21/10 and 11/1/10 on environmental surfaces throughout the hospital. The Infection Control Officer failed to ensure three hospital staff followed acceptable standards of practice and hospital policy for isolation precautions for 2 of 4 patients included in the sample. Failed to assure three staff members followed hand hygiene policies, and cleaning of equipment during patient care for 3 of 11 patients (Patient #'s 1, 2, and 16) and failed to assure the housekeeping staff followed hand hygiene policies and used cleaning supplies as specified by the manufactures recommendations when cleaning patient care rooms. See further evidence cited at CFR 482.42(a)(1), A 0749.

- Based on observation, document review and staff interview the Hospital ' s Infection Control Officer failed to maintain a log of incidents related to infections and communicable diseases including healthcare-associated infections and infections identified through employee health services including patients, staff, contract staff and volunteers.
The failure to monitor and track incidents related to infections and communicable diseases created a potential patients, staff and visitors could be exposed to healthcare-associated infections and communicable diseases. See further evidence cited at CFR 482.42, A 0750.

- Based on observation, document review and staff interview the chief executive officer, the medical staff and the director of nursing failed to ensure the Assessment and Performance Improvement (QAPI) program and training programs addressed known infection control and environmental incidents of mold growth to develop and implement a successful corrective action plans in affected problem areas. The failure of the chief executive officer, medical staff and the director of nursing to develop and implement successful corrective action plans to eliminate the widespread unidentified black substance and lack of general cleanliness of the hospital placed all patients, visitors, and staff at risk for health-associated infections. See further evidence cited at CFR 482.42(b)- A0756.

Based on observations, staff interview and document review the hospital ' s infection control officer failed to develop and implement an effective program to identify, report, investigate and take corrective action on black substances identified on 9/23/08, 5/21/10 and 11/1/10 on environmental surfaces throughout the hospital. The Infection Control Officer failed to ensure hospital three staff followed acceptable standards of practice and hospital policy for isolation precautions for 2 of 4 patients included in the sample. Failed to assure three staff members followed hand hygiene policies, and cleaning of equipment during patient care for 3 of 11 patients (Patient #'s 1, 2, and 16) and failed to assure the housekeeping staff followed hand hygiene policies and used cleaning supplies as specified by the manufactures recommendations when cleaning patient care rooms.

Findings Include:

- The Infection Control Committee- Authority statement, policy number 101 and Activities of the Infection Control Program, policy number 103, reviewed on 11/3/10, directed the Infection Control Committee to minimize infections and infection potential for patients, staff and visitors by maintaining measures for prevention, identification, reporting and control.

The policy stated the committee's responsibilities include: Implementing preventative measures to prevent and control infections. Oversee the Infection Control Program for surveillance, prevention and control of infections. The program will include: surveillance for infections in patients and staff, education for infection control prevention, consultation in infection control, employee health, laboratory reports and yearly policy reviews. To enforce all Infection Control Policies and to implement any appropriate control measures or conduct epidemiological studies when it is reasonably felt that there is a danger to patients and staff and communicate all concerns of risk to Infection Control Committee Members.

The policy identified the following staff as member for the Infection Control Committee were: Chief Executive Officer, Chief of Staff, Director of Nursing, Risk Management and Infection Control Officer. The committee will review infection control reports monthly and make recommendations.

Infection Control Officer D on 11/3/10 at 2:00pm verified the hospital lacked documentation of any Infection Control meeting minutes and reported the Hospital failed to hold monthly committee meetings.

- Tour of the Hospital' s five birthing rooms on 11/1/10 between 12:18pm to 4:30pm revealed birthing room #5 had a buildup of unidentified black substance on the wall and panel that contained oxygen, and patient call light controls. The buildup extended one to two inches above and below the wall unit. The vinyl wallpaper boarder contained the black substance under the rolled edges.

Maintenance staff M on 11/1/10 at 4:47pm acknowledged the Hospital had a humidity problem. Staff M put on gloves and mask then sprayed the wall in birthing room #5 with OxyFect H Peroxide a disinfectant, fungi static cleaner. Staff M soaked the wallpaper boarder with the cleaner and removed a seven foot section of the paper. The exposed wall under the paper contained spots of unidentified black substance on both the back of the wallpaper and the wall. Staff M reported the spots look like "mold".

Administrative staff A, B, C, D and Maintenance staff M on 11/1/10 at 5:20pm discussed the wall in the birthing room. Administrative staff D reported the hospital had "mold problems" at the beginning of this year.

Infection Control Officer D reported on 1/18/10 they discussed mold found in the medical records area with administration and noted problems with the carpet. The hospital sent samples of carpet tape to an outside laboratory for evaluation.

Staff A provided a "mold report" for review on 11/2/10 at 12:00pm. The document revealed the Hospital had two separate incidents with mold one dated 9/23/08 and a more recent reported dated 5/21/10.

The laboratory report dated 2/19/10 reviewed on 11/3/10 revealed the findings of: Penicillium species mold, hormonema dematioides mold and rhodotorula species yeast.

The hospital closed the medical records area, placed the medical records staff on leave from 2/19/10 to 2/22/10 until the offices were moved to another area. The hospital cleaned the equipment with microbial cleaner and sealed the area.

Observations of patient care areas on 11/1/10 and 11/2/10 between 12:45pm and 6:00pm revealed multiple rooms and patient areas with vents and dark build-up of an unknown black substance. There was an accumulation of dust, a dark build up of dirt, dirt around the threshold covers, bubbled paint with exposed rust on shelves under sinks, peeling and missing paint on windows and damaged walls with bubbled surfaces. See further evidence at CFR 482.41(a), tag A 0701.

The Hospital lacked evidence of any additional or ongoing environmental monitoring for black substance or mold or preventive measures.

- The Hospital ' s Infection Control log reviewed on 11/3/10 revealed the Infection Control Officer identified six patients with infections since 1/1/10, one patient with a potential Hospital Acquired Infection. Infection Control Officer D on 11/4/10 at 2:00pm reported they maintained a log for only potential hospital acquired infections and lacked evidence of any tracking for community based infections and staff infections.

- Patient #14 ' s medical record reviewed on 11/3/10 revealed the hospital admitted the patient on 8/29/10 diagnosed with bronchopneumonia; rule out MRSA (Methicillin resistant Staphylococcus aureus). Laboratory results of a sputum culture dated 9/1/10 identified "a large number of staph aurous growth" that required antibiotics to treat the infection. The closed record (including the plan of care) lacked evidence hospital staff placed patient #14 in isolation as required by hospital policy (to prevent the spread of a respiratory infection that requires droplet isolation).

Infection Control Staff D on 11/3/10 at 9:00am reported to prevent transmission of respiratory infection all pneumonia patients admitted to the hospital required droplet isolation until the cause of the infection was identified by laboratory results.

- Infection Control Officer D on 11/1/10 at 4:00pm reported the Hospital's current census 19 did not include any patients in isolation.

Observation on the hospital ' s medical surgical unit on 11/2/10 at 9:45am revealed patient #2 walked the hall with a family member.

Review of patient #2' s medical record on 11/3/10 at 10:30am with Administrative staff B, revealed the hospital admitted patient #2 on 11/1/10 with a diagnoses of lower left lobe pneumonia (a respiratory infection), possible left middle lobe mass, hypothermia, seizure disorder and mental retardation. The physician ordered intravenous antibiotics (Rocephin and Zithromax). Laboratory reports between 11/1/10 to 11/4/10 identified an increasing white blood cell (WBC) count (an indication of an on-going infection). Patient #2 ' s WBC continued to increase from 11.9 to 15.3 on 11/3/10 even with antibiotic treatment. The hospital failed to place patient #2 in isolation to prevent the possible spread of respiratory infection as required by hospital policies and procedures.

Administrative staff B and F on 11/2/10 at 11:02am reported " We implement isolation precautions based on nursing judgment." Staff B verified hospital staff failed to initiate isolation precautions for patient #2 diagnosed with pneumonia.

Administrative staff B and Infection Control Officer D on 11/3/10 at 9:00am acknowledged hospital staff failed to follow hospital policy and precautions for isolation with patient #2 created a risk of spreading the respiratory infection to other patients, staff and visitors.

- Registered Nurse U observed on 11/2/10 at 11:30am preformed a blood sugar check on patient #1 with a glucose monitor. Nurse U placed the glucose monitor (a machine used to monitor blood sugar) on the patient's contaminated bed. Nurse U picked up the glucose monitor with gloved hands and set the monitor on the patient's bedside table. Nurse U completed the test, sat the machine without a protective barrier next to the sink, removed their gloves and washed their hands. Nurse U carried the contaminated glucose monitor to the nurse's station, and then placed it into a plastic case. Nurse U reported hospital ' s laboratory staff cleaned the glucose monitor monthly. Nurse U stated nursing staff did not clean the glucose monitor between patient uses.

Policy for Sure Step glucose monitor dated 10/17/10 reviewed on 11/2/10 at 2:15pm directed the laboratory staff to clean the strip holder monthly and "clean meters monthly or if dirt, blood or lint" were present.

Infection Control Officer D and Administrative Staff B on 11/2/10 at 1:00pm acknowledged the Hospital ' s laboratory cleaned the internal parts of the glucose monitor monthly and reported the nursing staff would be responsible to clean the machine between patients to reduce the risk of spreading infections from patient to patient.

- Registered Nurse T provided patient #19's wound care on 11/2/10 at 2:20pm. Nurse T failed to follow acceptable infection control standards of practice and contaminated wound care supplies. Nurse T placed wound care supplies on top of the bed linens without a protective barrier to prevent contamination of the supplies. RN staff T washed their hands and removed one set of gloves from the box on the wall. RN staff T removed the soiled bandage to expose a surgical hip incision and two open wounds on the patient's left thigh. Nurse T placed the contaminated bandage in a red bag lying on the patient's bed.

Nurse T opened bandage packages of gauze and ABD pad with their contaminated gloves (glove change and hand hygiene should occur after removal of the contaminated dressing). Nurse T opened the medication Mupirocin with contaminated gloves, and applied the medications onto two cotton applicators.

Nurse T applied the medication to the wound, added additional Mupirocin cream to the contaminated applicator and reapplied the medication.

Nurse T reapplied additional medication from the tube on the contaminated used cotton applicator. Nurse T covered the wounds with gauze and taped ABD bandage in place without changing their contaminated gloves to apply a clean dressing.

Nurse T picked up the tube of medication from the contaminated bed linens and the red bag of contaminated supplies in their left hand, then placed the roll of tape over their left gloved index finger (like a ring). Nurse T placed the red biohazard bag on a countertop next to the sink and placed the tube of medication and tape next to the contaminated biohazard bag.

Nurse T reported they forgot to remove the charge stickers form the supplies and used the gloved hands to rummage through the red bag to remove the charge stickers from the soiled supplies and then discarded the bag in the trash can. Nurse T removed their gloves and washed their hands, and picked up the tube of contaminated medication with their bare hand.

The nurse left the tape in the patient ' s room and carried the contaminated tube of medication to the mobile computer stand and placed it into the patient ' s medication drawer. The nurse proceeded to type their notes on the community computer keyboard (used by all staff on the unit) without washing their hands.

Nurse T placed patients, visitors and staff at risk for hospital acquired infections by not following acceptable standards of infection control.

Administrative staff B and F on 11/2/10 at 2:35pm acknowledged nurse T should have washed their hands between dirty to clean and use separate swabs for each wound and not reapply the medication to the contaminated swabs. Staff B and F reported the nurse failed to properly handle contaminated supplies and should never rummage in a red bag to find charge stickers.

On 11/3/10 at 4:00pm Administrative staff B and F stated the hospital lacked policies and procedures for wound care.

- Observations of patient care areas on 11/1/10 and 11/2/10 between 12:48pm to 6:00pm revealed multiple rooms and patient areas with vents with dark build-ups of unknown black substances and accumulations of dust, flooring with a dark build up of dirt, dirt build up around thresholds covers, bubbled paint with exposed rust on the shelves under the sinks, peeling and missing paint on the windows, and damaged walls with bubbled surfaces, as cited at A-701.

The hospital reported an average daily census of 13 with 49 certified beds. Based on observation, document review and staff interview the Hospital ' s Infection Control Officer failed to maintain a log of incidents related to infections and communicable diseases including healthcare-associated infections and infections identified through employee health services including patients, staff, contract staff and volunteers. The failure to monitor and track incidents related to infections and communicable diseases created a potential risk to patients, staff and visitors who could be exposed to healthcare-associated infections and communicable diseases.

Findings include;

- The Infection Control Committee- Authority statement, policy number 101 and Activities of the Infection Control Program, policy number 103, reviewed on 11/3/10, directed the Infection Control Committee to minimize infections and infection potential for patients, staff and visitors by maintaining measures for prevention, identification, reporting and control.

The policy stated the committee responsibilities included: Implementing preventative measures to prevent and control infections. The program will include: surveillance for infections in patients and staff, education for infection control prevention, consultation in infection control, employee health, laboratory reports and yearly policy reviews. To enforce all Infection Control Policies and to implement any appropriate control measures or conduct epidemiological studies when it is reasonably felt that there is a danger to patients, staff and communicate all concerns of risk to Infection Control Committee Members.

The policy identified the following staff as member of the Infection Control Committee:
Chief Executive Officer, Chief of Staff, Director of Nursing, Risk Management and Infection Control Officer. The committee will review infection control reports monthly and make recommendations.

Infection Control Officer D on 11/3/10 at 2:00pm verified the hospital lacked documentation of any Infection Control meeting minutes including review of a log of incidents related to infections and communicable diseases for patients, staff, contract staff and volunteers. Staff D stated the Hospital failed to hold monthly committee meetings.

- The Hospital ' s Infection Control log reviewed on 11/3/10 listed only six patients with infections since 1/1/10. The Infection Control Officer failed to include staff, contract staff or volunteers infections. Infection Control Officer D on 11/3/10 at 2:00pm reported they maintained a log for only potential hospital acquired infections and lacked evidence of monitoring for community based infections and staff infections.

The Hospital ' s average daily census is 13 with 49 certified beds. Based on observation, document review and staff interview the chief executive officer, the medical staff and the director of nursing failed to ensure the Assessment and Performance Improvement (QAPI) program and training programs addressed known infection control and environmental incidents of mold growth to develop and implement a successful corrective action plans in affected problem areas. The failure of the chief executive officer, medical staff and the director of nursing to develop and implement successful corrective action plans to eliminate the widespread unidentified black substance and lack of general cleanliness of the hospital placed all patients, visitors, and staff at risk for health-associated infections.

Findings Include:

- Staff A provided a "mold report" for review on 11/2/10 at 12:00pm. The documented revealed the Hospital had two separate areas with mold, one identified by a laboratory report dated 9/23/08 and another area identified by a laboratory report dated 5/21/10.

The laboratory report dated 2/19/10 identified the following types of mold growing on the sample: Penicillium species mold, hormonema dematioides mold and rhodotorula species yeast.

Infection Control Officer D stated on 11/2/10 " the hospital ' s " staff became concerned the medical record room also had mold on 1/18/10. Employees were experiencing upper respiratory symptoms. The hospital took samples of carpet tape and sent them to an outside laboratory for analysis.

- Observations of patient care areas on 11/1/10 to 11/2/10 between 12:48pm to 6:00pm revealed multiple rooms and patient areas with vents with dark build-ups of unknown black substances and accumulations of dust, flooring with a dark build up of dirt, dirt build up around thresholds covers, walls and heater units with bubbled paint with exposed rust and wallboard. Multiple areas throughout the hospital had areas of dark, unidentified black substance on the wall, behind wallpaper, in vents and other environmental surfaces.

Maintenance staff M on 11/1/10 at 4:50pm stated the hospital had a humidity problem. Administrative staff A, B, C, D and Maintenance staff M at 5:20pm on 11/1/10 discussed the areas observed with an unidentified black, dark substances. Staff D reported the hospital had a " prior mold incident at the beginning of the year. "

- Interviews with administrative staff on 11/1/10 and 11/2/10 verified the hospital had knowledge of confirmed mold in several areas and observations with staff verified potential mold and a dirty environment throughout the hospital. The hospital ' s Quality Assessment and Process Improvement plan and monitoring data reviewed on 11/3/10 lacked any evidence the hospital developed and implemented a successful corrective action plan to eliminate the mold, unidentified black substance and maintain a clean environment.