HospitalInspections.org

Based on document review and staff interview, the facility failed to develop a system for identifying, reporting, investigating and controlling infections and communicable diseases for all patients and personnel. Findings include:

On 5/22/12 beginning at 1:00 p.m., the review of the facility infection control program began. Policies and procedures were developed and in place. Review of the infection log was completed. There was no documentation available of the review of monthly reported infections and the tracking of those infections to establish commonalities or sourcing of those infections.

During an interview with staff member C, the infection control officer, on 5/22/12 at approximately 1:20 p.m., staff member C stated that she did not track infections beyond collecting the data to report to Quality Assurance. The program did have criteria to establish whether the identified infections were community or hospital acquired, but there was no evidence that the infections identified during a specific month were reviewed for commonalities or trends. Staff member C stated that she was not aware that she needed to look at infections and look for trends or commonalities in the organisms or possible routes of transmission. There was no evidence available that would have established the potential sources of hospital acquired infections.