HospitalInspections.org

Based on observation, interview and record review, the facility failed to ensure a hospital-wide program was in place to prevent and control infections in 9 of 9 areas reviewed for infection control (front entrance of hospital, Coronavirus disease (COVID) unit, Emergency department (ED), Laundry, Main central supply, Lab, Wound care center, Progressive care unit, and Intensive care unit). The facility failed to:

A. ensure there was an effective infection control program which included an infection control committee and staff to assist with surveillance, infection control rounding and identifying infection control problems in the facility.

B. ensure visitor screening for COVID was performed per their internal policy.

C. ensure sterile and non-sterile supplies were stored in a manner to prevent cross contamination. They failed to ensure clean and soiled equipment were separated.

D. ensure lab supplies were transported under specified temperatures per the manufacturer. The facility failed to ensure lab and surgical supplies were transported in a manner to prevent cross contamination.

E. ensure physicians, nurses, and housekeeping staff used proper personal protective equipment (PPE) while working on the COVID unit.

F. ensure expired supplies were discarded and multi-dose vials were dated when opened.

G. ensure the lab was kept in clean and sanitary conditions.

H. ensure patient equipment and rooms were kept clean and sanitary

Refer to tag A0749 for additional information.

I. ensure there was a qualified individual who was appointed by the Governing body to be over the antibiotic stewardship. This was found in 1 of 1 physicians who was identified as being over the program (Physician #7).

Refer to tag A0760 for additional information.

Based on interview and record review, the facility failed to ensure there was a qualified individual who was appointed by the Governing body to be over the antibiotic stewardship. This was found in 1 of 1 physicians who was identified as being over the program (Physician #7).

This deficient practice had the likelihood to cause harm to all patients.

Findings include:



During an interview on 01/13/2022 after 10:22 a.m., Staff #50 (Interim Director of Pharmacy) said she had been in her position since 11/01/2021. Staff #50 said that the facility had only 2 of 4 pharmacy and therapeutic (P&T) meetings for 2021. Staff #50 said that Physician #7 was over the antibiotic stewardship program, but when staff had a question they called Physician #15.

Review of "NOMINATING COMMITTEE "minutes dated 09/20/2019 revealed Physician #7 was over the Pharmacy and Therapeutic committee. There was no mention of Physician #7 being over the antibiotic stewardship program.

Review of Physician #7's credentialing file dated 09/2021 revealed no documented training or education in infectious disease or antibiotic stewardship.

During an interview on 01/14/2022 after 8:10 a.m., Registered nurse #40 (Chief quality officer) confirmed the information in the credentialing file and committee minutes. Registered nurse #40 said she had already talked to Physician #7 and told him that they needed to get training on his file.