HospitalInspections.org

Based on review of records and staff interviews, the facility failed to provide documentation of the infection prevention and control program and its surveillance, prevention and control activities when there was no evidence of surgical site infection surveillance.

Findings:

The evidence of surgical site infection surveillance was requested and was not provided.

In an interview on the morning of 9/25/24, Staff #8, Infection Control Officer verified there was no documentation of SSI (Surgical Site Infection) moitoring and each patient who had surgery was not reviewed..

There was no documented evidence provided of nosocomial or surgical site infection surveillance conducted after 30 days or implant infection surveillance conducted after 90 days.

CDC procedure-associated module titled "Surgical Site Infection (SSI) Event," dated January 2024 found at: https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf stated in part, "SSI monitoring requires active, patient-based, prospective surveillance. Concurrent and postdischarge surveillance methods should be used to detect SSIs following inpatient and outpatient operative procedures.
For example, these methods include:
o Review of medical records or surgery clinic patient records
o ...Visit the ICU and wards - talk to primary care staff
o Surgeon surveys by mail or telephone
o Patient surveys by mail or telephone (though patients may have a difficult time assessing their infections).
Any combination of these methods (or other methods identified by the facility) with the capacity to identify all SSIs is acceptable for use ..."

Based on record review and staff interview, the facility failed to ensure competency-based training and education of personnel and staff on the practical applications of infection prevention and control guidelines, policies and procedures.

Findings were:

Review of personnel records for Staff # 24 and 25 revealed no documented training or orientation, including no documented training regarding infection control.

In an interview on the afternoon of 09/24/24, Staff #58, Housekeeping Director, reported housekeeping staff received infection control training, including training on the new disinfectant, Master Blend QUAT 256, but confirmed there was no documentation of the training and could not verify each staff received the training.

In an interview on the afternoon of 09/25/24, Staff #8, Infection Control Officer, reported they completed training with the housekeeping staff regarding the new disinfectant, Master Blent QUAT 2567, but confirmed there was no documentation of the training and could not verify each staff received the training.