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Based on observation, interview and record review, the facility failed to ensure physician's orders for Patient 10's indwelling Foley catheter, included the reason for the invasive device. This failure had the potential to increase Patient A's likelihood of acquiring a catheter associated urinary tract infection without adequate indication for catheter use.

Findings:

On October 20, 2011, at 2 p.m., Patient 10 was interviewed. Patient 10 was lying on a gurney in room one, in the emergency department. Patient 10 stated she did not know how long she had been in the ED, but she was having abdominal cramping.

On October 20, 2011, at 2:05 p.m., a Foley catheter (a tube placed into the bladder to continuously drain urine) was inserted into Patient 10's bladder by Staff L.

Patient 10's record was reviewed with ADM Staff H on October 20, 2011, at 2:15 p.m. Physician's orders at 12:30 p.m., indicated "Foley Cath (catheter)." There was no documentation regarding the indication for the Foley catheter for Patient 10. ADM Staff H stated she would inquire as to the reason for placement, but there was no documentation in the record as to why the Foley catheter was placed.

During an interview with Staff L at 2:15 p.m., Staff L stated Patient 10 was here for nausea and vomiting, with a history of a bowel obstruction, so they were monitoring the patient's output.

Additional review of Patient 10's record, conducted on October 20, 2011, indicated the patient was brought to the emergency room via ambulance at 12 p.m. According to the "Emergency Department Record," Patient 10's prior medical history included gallstones, congestive heart failure, atrial fibrillation (an irregular heart beat) and chronic obstructive pulmonary disease. Patient 10's ESI (Emergency Severity Index-triage acuity scale 1-Resuscitation, 2-Emergent, 3- Urgent, 4-Nonurgent, and 5-Referred) was documented as 3. In the section for assessing the urinary system, Patient 10 was identified as "Within Normal Limits."

The facility's policy and procedure titled "Catheter Associated Urinary Tract Infection Prevention," with a created and revised/reviewed date of October 2010, was reviewed on October 20, 2011. The policy indicated: "Healthcare -associated urinary tract infections (UTIs) substantially contribute to morbidity, mortality, healthcare costs, antibiotic use and other infections." The policy indicated the urinary tract was the most common site of healthcare associated infection and the recommendations in the policy would assist in the prevention and control of HAI associated with the use of a urinary Foley Catheter.

On October 20, 2011, at 3 p.m., the Staff E was interviewed about the lack of documentation in Patient 10's record regarding the Foley catheter use. Staff E stated the physician should be documenting the indication for use when ordering a Foley catheter.

Based on observation, interview, and document review, the hospital failed to develop a system for controlling infections and communicable diseases of patients and personnel.

1. The hospital failed to ensure hand hygiene was performed after clean gloves were removed and sterile gloves were donned (to put on);

2. The hospital failed to ensure reusable equipment was stored, cleaned, and disinfected in accordance with policy and procedure;

3. The hospital failed to ensure staff responsible for cleaning and disinfecting rooms between patients were trained and competent to perform the procedure;

4. The hospital failed to ensure the inside of the ice machines were routinely disinfected;

5. To reduce the risk of patients developing surgical site infections, the hospital failed to ensure the total number of air exchanges was maintained in all surgical procedure rooms;

6. The hospital failed to ensure that equipment used to high level disinfect flexible endoscopes was routinely cleaned;

7. The hospital failed to ensure all areas were clean and sanitary;

8. The hospital failed to ensure media used for stool specimens was not available for use after the manufacturer's expiration date;

9. The hospital failed to ensure surgical scrub brushes were not available for use after the manufacturers' expiration date, and failed to implement their surgical scrub policy and procedure;

10. The hospital failed to ensure all surfaces in surgery surgical suites were intact and could be disinfected between patients, and;

11. The hospital failed to ensure hand hygiene was performed by all health care workers before entering the surgical suite where sterile supplies and equipment were open and ready to use.

These failed practices had the potential to result in the spread of infection and communicable diseases.

Findings:

1. The hospital failed to ensure that hand hygiene was performed after clean gloves were removed, and sterile gloves were donned (put on).

On October 19, 2011, at 10:15 a.m., Staff A stated that she had a mid line (a peripheral intravenous line, that usually ends at the mid basilic/cephalic vein. It does not extend past the axilla), dressing change. Staff A stated the hospital treated mid line intravenous (IV), catheters, the same as central venous catheters (catheters that extend past past the axilla), and considered the dressing change a sterile procedure.

On October 19, 2011, at 10:20 a.m., Staff A was observed removing Patient 1's dressing that covered the right arm, mid line IV catheter. Staff A was then observed removing clean gloves (used to remove the dressing covering the mid line catheter insertion site), and don sterile gloves. Staff A did not perform hand hygiene before donning the sterile gloves. Staff A then proceeded to cover the right arm mid line IV with a sterile dressing. It was noted Staff A wore a surgeon's mask during the dressing change procedure.

During an interview on October 19, 2011, at 10 a.m., Staff A, was asked why hand hygiene was not performed before she donned sterile gloves. Staff A stated alcohol based hand rub (ABHR) was not available at the patient's bedside. Staff A added that leaving the bedside to perform hand hygiene would leave the mid line IV insertion site exposed, which could result in possible contamination of the site. Staff A confirmed hand hygiene should have been performed before donning sterile gloves.

On October 19, 2011, at 5 p.m., the Association for Professionals in Infection Control and Epidemiology (APIC), textbook, published in 2009, was reviewed. Suggested techniques in section 20-2, recommended that during a central line dressing change: hand hygiene was indicated; sterile gloves should be used for removing old dressing, and new sterile gloves for dressing change procedure. APIC also recommended , "...aseptic practices include providing maximum reduction of skin microorganisms with damaging tissue, which is accomplished when healthcare provides decontaminate their hands before donning sterile gloves..."

2. The hospital failed to implement their policy and procedure ensuring all reusable patient care equipment was stored, cleaned, and disinfected in accordance with hospital policy.

a. On October 19, 2011, at 8:50 a.m., a tour was conducted of the intensive care units on the first floor. The two closets labeled as, "Clean equipment" were inspected. One closet had two IV pumps sitting on the floor, and the second closet had one pump sitting on floor.

During a concurrent interview, Staff B stated it was not hospital practice to store clean IV pumps on the floor.

b. On October 19, 2011, at 1:30 p.m., Staff C was observed cleaning a labor and delivery room after a patient was discharged from the room. During the cleaning process, Staff C was observed wiping down the IV pump that was in the labor and delivery room. It was also noted a pulse oximeter (equipment used to measure a patients' oxygen level), sitting on a metal table, was not cleaned by Staff C.

During a concurrent interview, Staff D was asked to explain the hospital's process for cleaning and disinfecting equipment between patients. Staff D stated it was hospital practice to send all patient care equipment to central service for cleaning and disinfection between patients.

On October 19, 2011, at 5:30 p.m., the hospital's policy and procedure dated, October 2010, and titled, cleaning of reusable equipment, was reviewed. It was noted the policy and procedure was listed as a central service policy / procedure. It was noted under the policy section, all patient care areas were responsible for returning used equipment and trays to the soiled utility area for decontamination and reprocessing in a manner that will contain and confine contamination.

3. The hospital failed to ensure staff responsible for cleaning and disinfecting rooms between patients were trained and competent to perform the procedure.

On October 19, 2011, at 1:30 p.m., Staff C was observed cleaning a labor and delivery room after a patient was discharged from the room. During the cleaning process the following observations were noted:

a. While cleaning the two bed pillows, Staff C, cleaned one side of a pillow, then flipped the clean side down, onto the soiled pillow stacked underneath.

b. After cleaning and decontaminating the two bed pillows, both pillows were placed on the labor / delivery bed, which had not been cleaned. It was noted the two pillows were not re-cleaned.

c. During the cleaning process, a metal table was observed sitting against the far wall. It was noted the metal table was covered with a bed sheet. A pulse oximeter, a stack of clean washcloths, and three moisture proof pads were observed on top of the bed sheet. During the cleaning process (which included cleaning the walls, over-head light, and mopping the floor) the bed sheet covering the metal table, the oximeter, and other supplies on the table, were not removed, or discarded by Staff C. It was also noted the bed sheet, oximeter, and other supplies on the bed sheet were still in the room when clean linen and other supplies were brought into the room for the next patient.

d. Staff C, was observed, wearing gloves worn during the cleaning process, going to the housekeeping supply cart. Staff C was observed placing her gloved hands into a box of clean gloves (contaminating the gloves in the box). It was noted Staff C also contaminated the clean unused cleaning cloths, that were on top of the cart. Staff C stated she was looking for her safety goggles.

e. It was noted the top of the fetal monitoring cart (cart sitting next to the labor / delivery bed, containing equipment and supplies used to monitor the mother and baby during labor), was not cleaned and disinfected, before clean linen and other supplies were brought into the room for the next patient.

f. While cleaning the labor / delivery cleaning room, Staff C was observed re-dipping the two cleaning cloths in the disinfectant solution (not discarding the cleaning cloths after one dip into the disinfectant solution), and re-used the two cleaning cloths to clean, additional surfaces in the room. It was noted when Staff C completed cleaning the labor / delivery room, an inspection of the bucket containing disinfectant solution, revealed the color of the disinfectant solution was grey and cloudy.

During a concurrent interview, Staff D was asked if it was usual practice to leave patient care equipment and supplies, on the counters before the labor / delivery rooms were cleaned. Staff D stated the labor and delivery rooms followed the same practice as the surgical suites, and all exposed equipment and patient care supplies removed, or discarded, before beginning the cleaning process.

During an interview on October 19, 2011, at 2 p.m., Staff E was asked if she had trained hospital staff on how to clean the labor/delivery rooms. Staff E stated she was new to her position. Staff E stated training, education, and staff competency, had not been high on the priority list. When asked, if it was acceptable for staff to leave exposed equipment and supplies in the labor/delivery rooms before the cleaning process, Staff E replied, no, it was not. Staff E was then asked if it was hospital practice to re-dip used cleaning cloths into the disinfectant solution, she replied, "absolutely not."

On October 19, 2011, at 3 p.m., a request was made to review Staff C's competency records. Staff C's competency records were reviewed, and revealed there was no evidence Staff C had received training, or was competent to clean labor/delivery rooms between patients.

4. The hospital failed to ensure the inside of the ice machines were routinely disinfected.

On October 19, 2011, at 3 p.m., a request was made to review the reports showing the inside of the ice machines were routinely cleaned/disinfected.

On October 20, 2011, at 10 a.m., Staff F was interviewed. During the interview, Staff F stated his department was responsible for cleaning the outside surface of the ice machine. Staff F stated plant operations was responsible for cleaning/disinfection inside the ice machines.

On October 20, 2011, at 11 a.m., Staff G, was asked for documentation showing the inside of the hospital's ice machine were cleaned/disinfected. Staff G had no documentation showing the inside of the hospital's ice machine were routinely cleaned and disinfected.

5. To reduce the risk of patients developing surgical site infections, the hospital failed to ensure the total number of air exchanges was maintained in all surgical procedure rooms.

During the entrance conference on October 19, 2011, at 9 a.m., Administrative Staff H, stated pacemakers (device surgically inserted in the chest or abdomen to help control abnormal heart rhythms), were routinely inserted in the cardiac catherization lab.

On October 20, 2011, at approximately 9:10 a.m., a surgical procedure was performed in the cardiac catherization room.

On October 20, 2011, at 10 a.m., a request was made for the air exchange report for the cardiac catherization room. The air balance report dated 2008, was provided and reviewed. Documentation in the air balance report revealed the cardiac catherization room had 5 total air exchanges per hour.

During a concurrent interview, Staff G confirmed the cardiac catherization room had 5 total air exchanges per hour.

On October 20, 2011, at 1 p.m., the 2011, The Association of periOperative Registered Nurse (AORN), Perioperative Standards and Recommended Practices was reviewed. Under Recommendation V, on page 219, item, V.d.1., AORN recommended , "The air-exchange rate in the perioperative area should be carefully controlled. The number of air changes per hour is based upon the need to remove microbiological or chemical contaminants from the environment." Under item, V.d.1., AORN, recommended , "The minimum rate of total air exchanges per hour should be maintained at a constant level as follows: Operating room: minimum of 15 air exchanges per hour with a recommended range of 20 to 25 air changes....Postanesthesia care unit: six air exchanges per hour. Compressed gas area: eight air exchanges per hour. Sterile storage area: four air exchanges per hour." Under item V.d.1., AORN recommended , "Air exchanges per hour should be monitored per the organization's policy." Under item V.e., AORN, recommended, "Air-flow patterns within the perioperative setting should be controlled and uninterrupted. Air-flow patterns are architecturally designed and engineered to minimize contamination of the sterile field. Disruptions in the air-flow patters within the operating room can redirect contaminates onto the sterile field, increasing the risk of surgical site infection."

6. The hospital failed to ensure equipment used for high level disinfection was routinely cleaned and maintained according to manufactures' recommendations.

On October 19, 2011, at 10:45 a.m., a tour was conducted of the GI (gastrointestinal), lab. An inspection of the room where flexible endoscopes are cleaned and high level disinfected (chemical process used to reprocess equipment that cannot be steam sterilized) was conducted. The machine used for high level disinfection (HLD) was inspected. It was noted the entire top ridge of the tub (items to be high level disinfected are placed inside), was covered with brownish residue.

During a concurrent interview, Staff I was asked if the department had a policy and procedure describing the process for cleaning the HLD tub. Staff I replied the department did not have a policy or procedure for cleaning the tub of the HLD machine. A second request was made to review, the manufacturer's guide for routine maintenance of the HLD machine. Staff I stated the HLD machine was old, and she didn ot think she had a manufacturer's maintenance guide.

On October 20, 2011, at 1 p.m., the 2011, Association of periOperative Registered Nurse (AORN), Perioperative Standards and Recommended Practices was reviewed. Under Recommendation X, on page 408, AORN recommended , "Policies and procedures for high-level disinfection should be developed using the validated instructions provided by the medical device manufacturers, reviewed at regular intervals, revised as necessary, and readily available in the practice setting."

7. The hospital failed to ensure all areas of the hospital were clean and sanitary.

On October 19, 2011, at 1:20 p.m., a tour was conducted of the labor and delivery area of the maternity department. During the tour, it was noted the foot pedal for the waterless surgical scrub had slipped underneath the scrub sink. As the foot pedal was pulled from under the scrub sink, approximately a half inch of dust and dirt was observed on the floor below the scrub sink.

During a concurrent interview, Staff D was asked about the frequency for environmental cleaning of the scrub sink area. Staff D replied the scrub sink area was routinely cleaned daily, and more often if needed. When asked if she thought the amount of dirt and dust under the scrub sink had accumulated during the past 24 hours, Staff D replied, "I don't think so."

8. The hospital failed to ensure media used for stool specimens was not available for use after the manufacturer's expiration date.

On October 19, 2011, at 8:50 a.m., a tour was conducted of the first floor intensive care unit. During the tour, the soiled utility room, across from room 159, was inspected. Two different boxes of culture media for stool specimens were observed. One box labeled as Para Pac C&S (culture and senility medium), contained about 30 ml (milliliter), bottles. The manufacturer's stamped expiration date (do not use after) was 3/2008. The second box, labeled as Para Pac, ECO Fix (used for parasites and enteric pathogens), contained about 27 Ml bottles. The manufacturer's stamped expiration date was 8/2009.
During a concurrent interview, Staff B, confirmed the culture media was past the manufacturer's do not use after date, and should not be available for use.



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9. During a tour of the labor and delivery area, on October 19, 2011, at 10:30 a.m., a prep sink was observed. Two boxes of surgical scrub brushes/sponges were observed on the wall over the sink. The boxes contained disposable combination scrub brushes and sponges with enclosed nail cleaner. Both boxes had hand written notes that indicated "Exp (expiration) 9/11 (September 2011). A single container was pulled from the box and reviewed with Staff D. The container indicated an expiration date of September 2011.

During an interview with Staff D, on October 19, 2011, at 10:30 a.m., Staff D stated the brushes/sponges had expired and should be removed. The Manager stated the integrity of the packaging could be compromised and the brushes were available for use 19 days after their expiration date.

On October 19, 2011, at 2 p.m., a tour of the surgical department was conducted. Surgical prep sinks were located outside the operating rooms. Boxes of surgical scrub brushes/sponges were observed on the wall over the sink. Also noted was a container of "Surgicept-Waterless Hand Scrub."

During an interview with Staff I on October 19, 2011, at 2:15 p.m., Staff I stated surgical staff can perform a five minute scrub with soap and water or a waterless scrub after an initial hand wash. Staff I stated policies were available for both practices and neither practice was wrong.

On October 19, 2011, at 3:15 p.m., ADM Staff H was interviewed. ADM Staff H stated the physician's and staff in the labor and delivery area should conform to practices followed by surgical staff. ADM Staff H stated OB staff should be performing a surgical scrub prior to vaginal delivery.

The facility's policy and procedure titled "Surgical Hand Wash Scrub," with a created, revised reviewed date of October 2010, was reviewed on October 20, 2011. The policy indicated the purpose of the hand scrub was to mechanically and chemically reduce microbial flora on the skin of hands and forearms of the surgical scrub team. The policy indicated a key point was the antimicrobial soap or detergent, and to see manufacturer's instructions for scrubbing recommendations. The policy also referenced the Association of periOperative Registered Nurses (AORN), Perioperative Standards and Recommended Practices, 2010 Edition.

The Association of periOperative Registered Nurses (AORN), Perioperative Standards and Recommended Practices, 2011 Edition was reviewed on October 20, 2011. The standards included the following about hand hygiene for surgical and invasive procedures: Hand hygiene has been recognized as a primary method of decreasing health care-associated infections. Prevention of health care-associated infections is a priority of all health care personnel. Hand hygiene, hand washing, and surgical hand scrubs are the most effective way to prevent and control infections and represent the least expensive means of achieving both.

10. On October 20, 2011, at 9:10 a.m., Patient 11 was placed in the Cardiac Cath Lab for a Pacemaker/ICD (implantable cardioverter defibrillator) insertion. The room was set up with sterile equipment and staff entering the room were dressed in surgical scrub attire. The procedure, performed under sterile precautions, was completed at 11:15 a.m., and Patient 11 was transferred to a gurney and taken to the recovery area adjacent to the Cardiac Cath Lab.
During an interview with Staff J on October 20, 2011, at 11:15 a.m., Staff J stated housekeeping would do a "terminal clean," of the room as they do a terminal clean after every case. Staff J stated there were no other cases scheduled for today. Staff J stated they did not have a dedicated housekeeper, but housekeeping was very prompt when a cleaning was requested.

On October 20, 2011, at 11:15 a.m., Staff I was interviewed. Staff I stated a "terminal clean," consisted of taking everything off the counters and cleaning every surface of the room. Terminal cleans for each room, were conducted at the end of planned procedures for the day.

a. On October 20, 2011, at 11:20 a.m., Staff K arrived to clean the Cardiac Cath Lab. Staff K brought into the room a stack of wet washcloths. The wash clothes were folded into quarters and were placed on the Cath Lab table mattress. The cloths, while wet were not saturated or dripping with cleaning solution. Staff K used the four clothes to wipe down items in the room. From a distance, the items did not appear wet for an extended period of time.

During an interview with Staff K, on October 20, 2011, at 11:30 a.m., Staff K stated she used a disinfectant solution on each item. Staff K stated the item should remain wet for five minutes following the application. The Housekeeper also stated she did not reapply the solution if the item was dry before that time.

b. Staff K was observed picking up items on a countertop, cleaning under the item and placing the item back on the cleaned counter. Staff K moved to the table and began wiping down surfaces of the table. Reusable items were left where they were. The items were not moved to the other side of the room. Staff K lifted the Cath Lab table mattress up at the top end, but did not entirely remove the mattress from the table and did not completely wipe down the mattress. The upper portion of the Cath Lab table was cleaned with a washcloth, and the mattress was immediately replaced on the table. The cath table was not broken down. Staff K used one mop and began mopping the room near the back door, then completed mopping on her way out of the room at the other entrance.

c. On October 20, 2011, at 11:20 a.m., when Staff K was observed lifting up the mattress from the procedure table, the mattress was observed to have a large tear to the moisture barrier on the back. Approximately 20 % of the back of the mattress did not have the attached plastic covering in place.

d. On October 20, 2011, at 11:15 a.m., at the conclusion of Patient 11's procedure, the scrub tech and x-ray technician were observed wiping reusable items (blood pressure, cardiac monitors wires and connectors) with Sanicloth Plus. Oxygen connector tubing and suction tubing (single patient use items) were left connected to the oxygen connector and the suction bottle.

On October 20, 2011, at 11:20 a.m., Staff K was observed cleaning the Cardiac Cath Lab procedure room. Staff K cleaned around the oxygen tubing and suction connector and did not remove from the newly cleaned area.

During an interview with Staff I, on October 20, 2011, at 11:30 a.m., Staff I stated the oxygen and suction tubing should be removed by staff after the patient's procedure was over and before the room was cleaned.

During an interview with Staff J, on October 20, 2011, at 12 p.m., Staff J stated he should have removed those items, but he was recovering the patient and had not gotten to it.

On October 20, 2011, the policy and procedure titled "Surgical Care Area-End of Day Cleaning," with a revised date of December 2010, was reviewed. The policy indicated its purpose was to maintain a clean hygienic environment for patient, staff or visitors by cleaning in surgical areas at the end of the day's scheduled cases. Procedures included an identification of patient areas covered by the policy. Areas included invasive Suites in OR, Labor and Delivery and the Cath Lab. The policy indicated the following:

"3. Remove all portable equipment to one side of the room.

4. On the empty side of the room: wash all walls, ceilings, doors and frames, electrical outlets, phones, rubber hoses, fixtures attached to walls and ceiling, outside surface monitors, cabinets and shelves with germicidal solution...

6. Clean all portable equipment and furnishings using clean cloths saturated with approved germicidal solution.

a. Procedure Table, break it down to get to all exterior parts and clean from the top down to the floor..."

On October 20, 2011, at 1 p.m., the Director of Environmental services was interviewed. The Director stated the disinfectant had a ten minute contact time and should be reapplied if it dried prior to ten minutes.

On October 20, 2011, the reference sheet for A-456 II (the disinfectant cleaner used by the facility) was reviewed. Directions for use indicated "apply use-solution to hard nonporous surfaces, thoroughly wetting surfaces with a cloth, mop, sponge, sprayer or by immersion. Treated surface must remain wet for 10 minutes."

The Association of periOperative Registered Nurses (AORN), Perioperative Standards and Recommended Practices, 2011 Edition was reviewed on October 20, 2011. The standards included the following: Mattresses and padded positioning device surfaces (eg, OR beds, arm boards, patient transport carts) should be moisture-resistant and intact. Damaged or worn coverings should be replaced.

11. On October 19, 2011, at 2:20 p.m., Operating Room techniques were being observed. Room 4 was set up and a patient was brought to the room for an orthopedic surgery. Staff present in the room were wearing scrub attire and surgical masks. Physician A was observed walking up to the sink next to room 5, obtaining a mask and entering the room. Physician A did not wash his hands at either of the sinks in close proximity to room 4.

During a concurrent interview with Staff I, on October 19, 2011, at 2:20 p.m., Staff I stated the expectation was that hand hygiene be performed right before entering the room.

Based on interview and document review, the hospital failed to demonstrate that the infection control program completed recommended risk assessments, collected data, analyzed, and acted on infection control data.

Findings:

1. The hospital failed to complete an annual assessment to determine their risk or incidence of tuberculosis in their community.

On October 19, 2011, at 3 p.m., a request was made to review the hospital's most recent tuberculosis (TB), risk assessment.

On October 20, 2011, at 10 a.m., a Centers for Disease Control and Prevention form, titled, IP.13.C - Appendix C. Tuberculosis (TB), risk assessment worksheet was provided. The form was dated September 27, 2006. It was noted that the form was blank.

During an interview on October 20, 2011, at 2 p.m., Staff E confirmed she could provide no evidence showing the hospital had completed a TB risk assessment.

On October 20, 2011, at 2:30 p.m., Centers for Disease Control and Prevention (CDC) Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, published in 2005 was reviewed. Recommendations in the document was that each hospital should complete an annual risk assessment, using infection data from the previous year, to determine the risk or incidence of TB in the community.

2. The hospital failed to collect infection control data, and develop an action plan addressing the affected areas.

On October 20, 2011, at 11 a.m., a request was made to review the hospital's infection control log for the past 12 months. The infection control log was provided, reviewed, and the following was noted: Excluding an Escherichia coli (E. coli) (a Gram-negative, bacteria) infection reported on March 7, 2011, no infection data was previously reported. Documentation in the infection control logs also showed the majority of infections were reported beginning in May 2011.

During a concurrent interview, Staff E stated she was hired by the hospital in June 2011. Staff E stated she was going back through infection control reports, attempting to validate and create infection logs.

On October 20, 2011, at 11:30 a.m., the infection control meeting minutes for February 17, 2011, April, 4, 2011, June 7, 2011, and August 8, 2011, were reviewed. Documentation in the February 17, 2011, infection control meeting minutes made reference to an Acinetobacter baumanni (Gram-negative bacteria), incident. The meeting minutes referenced an attached report. No evidence of an attached report was found. Additional documentation in the infection control meeting minutes contained no evidence that the infection control committee had analyzed the infection reports, or developed action plans for the affected areas.

During a concurrent interview, Staff E was asked if she had any additional information about the Acinetobacter baumanni incident. Staff E stated all she knew was the incident occurred in the intensive care unit. Staff E was unable to provide information as to the number of patients involved, or if any action was taken by hospital administration. When asked if she was aware if staff working in the intensive care unit received education on hand hygiene and environmental cleaning, she replied, she had no evidence showing training was provided.