HospitalInspections.org

This is a repeat deficiency from a survey completed on 09/14/12.


Based on document reviews and interview, the hospital failed to ensure that there was an active infection control surveillance program that was related to infections and communicable diseases, including those that were identified through employee health services. This deficient practice could result in the lack of specific measures for prevention, early detection, control, education and investigation of infections. The absence of such measures increases the risk of infection to patients, visitors and staff. The findings are:

A. Review of the facility's infection control log book and the surveillance rounds documentation revealed no evidence of tracking or monitoring central and peripheral venous lines and urinary catheters.

B. On 04/03/13 at 11:00 am, during interview, the Director of Nursing/Infection Control Preventionist was asked about the monitoring and surveillance of hospital-acquired infections relating to port-a-caths. She responded, "I really don't monitor that."