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Based on observation, interview, and record reviews, the hospital does not have an infection control program which identifies, monitors, or controls the transmission of Multi Drug Resistant Organisms (MDRO). The hospital has not implemented corrective measures as recommended by the local health department's epidemiologists to eliminate Carbapenem Resistant Acinetobacter Baumannii (CRAB), a multi-drug resistant organism.

The findings include:

1. Interview with the Nurse Manager of the Intensive Medical Care (IMC) Unit at 10:00 am on 10/23/12 revealed that the facility does not have a surveillance program to test for Multi Drug Resistant Organisms (MDRO). When asked if the Nurse Manager was aware of the local health department recommendations for screening and surveillance for MDRO, she stated that she was aware. Further, she stated that the nurses in the unit must request cultures from the individual physicians to obtain an order.

2. An interview was conducted with the Infection Control Preventionist, (ICP) on 10/23/12 at 2:00 pm. The surveyor requested the surveillance and monitoring log for the Carbapenem Resistant Acinetobacter Baumannii (CRAB); a multi drug resistant organism. A review of the cases for July, August, September, and three weeks of October, 2012 were conducted. She verified that the facility had 7 cases total for these months. The log was compared to the facility laboratory log of reported cases to the Volusia County Health Department for the same dates. The total count was 14. The facility-wide infection control monitoring and line list of CRAB infection for the MDRO was not correct.

3. Reports from the local health department revealed that the hospital has continued to have CRAB, MDRO infections and has not followed a plan to implement the recommendations of the epidemiologists, which included initial surveillance screening cultures on admission to special at risk units, maintaining an electronic line list of all patients infected or colonized with CRAB on a daily basis and reporting weekly to the health department, and to ensure adequate staffing of Infection Control Preventionists.

4. Patient #31 may have contracted the CRAB, MDRO, and is documented as "HA" (hospital acquired). The patient did receive sputum and blood cultures on 9/14/12 (admission), which were negative. On 10/14/12, the blood tested positive for CRAB, and the sputum positive for Methycillin Resistant Staphylococcus Aureus (MRSA).

5. Further interview of the contract Infection Control Preventionist on 10/23/12 noted the hospital has one additional Registered Nurse assigned to the infection control program and is planning to hire an Infection Control Preventionist. Additionally, there is no admission surveillance program for MDRO, which includes CRAB. The ICP stated that she is aware that this is not in accordance with CDC guidelines (MDRO, 2006).

This deficiency was previously cited on June 12, 2012.