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Based on observation, facility record review, and interviews with staff, the governing body failed to provide the necessary resources and direction to facility management to ensure that the policies and procedures for identifying patients with Carbapenem Resistant Acinetobacter Baumannii (CRAB), monitoring patients with CRAB, and providing intervention activity to ensure that CRAB was not being transmitted to other patients in the hospital.

The findings include:

1. Interview with the Nurse Manager of the Intensive Medical Care (IMC) Unit on 10/23/12 at 10:00AM revealed that the facility does not have a surveillance program to test for Multi Drug Resistant Organisms (MDRO).

2. Interview with the Infection Control Preventionist, (ICP) on 10/23/12 at 2:00 PM was conducted. The surveyor requested the surveillance and monitoring for the Carbapenem Resistant Acinetobacter Baumannii (CRAB), a multi drug resistant organism. The ICP reviewed the log of cases for July, August, September, and three weeks of October, 2012. She verified that the facility had 7 cases total for these months.

The log was compared to the facility's laboratory log of reported cases to the Volusia County Health Department for the same dates. The total count was 14. The housewide infection control monitoring and line list of CRAB infections for the MDRO was not correct. When asked about active surveillance of the facility, it was revealed that the Food Service and Laundry facilities were not included to determine if potential CRAB was in these areas. There was no reason given for why these areas were not monitored.

3. Reports from the local health department revealed that the hospital has continued to have CRAB and MDRO infections, and have not followed a plan to implement the recommendations of the epidemiologists, which included: initial surveillance screening cultures on admission to special at risk units, maintain an electronic line list of all patients infected or colonized with CRAB on a daily basis and to report weekly to the health department, and to ensure adequate staffing of Infection Control Preventionists.

4. Further interviews with the contract Infection Control Preventionist on 10/23/12 at 2:00PM revealed the hospital had one additional Registered Nurse assigned to the infection control program and was planning to hire an Infection Control Preventionist. Additionally, there was no admission surveillance program for MDRO, which includes CRAB. The ICP stated that she was aware that this is not in accordance with CDC guidelines (MDRO, 2006).

The failure of the work above continues to put all patients in the facility at risk of infections that are preventable with the procedures in the CDC guidelines for Multiple Drug Resistant Organisms (MDRO, 2006).


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Based on observations of the Intensive Medical Care Unit with the Nurse Manager on 10/23/12, and observation of the laundry area with the Risk Manager on October 25, 2012, the physical environment and maintenance of the building's walls, baseboards, and four patient rooms were not maintained within acceptable standards.

The findings include:

1. The wall paper was observed loose, unraveled, or missing pieces outside of Rooms #519, #522, #507 and #508.

2. Room #522's water faucet pan was dark with corrosive appearance and soiled. The wall paper was missing pieces and baseboards were partially attached.

3. The door frames throughout the unit were soiled and contained debris.

4. The laundry room does not have the required positive pressure in the clean area. Changes to the building have positive pressure in the dirty area that is moving into the clean area of the facility. When clean laundry is set up and ready to move, the clean laundry is taken back through the dirty area to a common dock where dirty laundry is being separated for cleaning. In addition, the room was not clean.

An interview with a laundry manager on October 25, 2012 at 11:00 AM revealed that the lint that was covering all flat surfaces in the laundry area was only cleaned once per week. The amount of lint in the air and the clean laundry, mixed with contaminated air coming from the dirty laundry area, provides a high potential for cross contamination.


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Based on observations, interviews, and record reviews, the hospital does not have an infection control program which identifies, monitors, or controls the transmission of Multi Drug Resistant Organisms (MDRO). The hospital has not implemented corrective measures as recommended by the local health department epidemiologists to eliminate Carbapenem Resistant Acinetobacter Baumannii (CRAB), a multi- drug resistant organism.

The findings include:

1. Interview of the Nurse Manager of the Intensive Medical Care (IMC) Unit on 10/23/12 at 10:00 AM stated that the facility does not have a surveillance program to test for Multi Drug Resistant Organisms (MDRO). When asked if the Nurse Manager was aware of the local health department recommendations for screening and surveillance for MDRO, she stated that she was aware. Further, she stated that the nurses in the unit must request cultures from the individual physicians to obtain an order.

2. During the interview of the Infection Control Preventionist, (ICP) on 10/23/12 at 2:00 PM, the surveyor requested the surveillance and monitoring for the Carbapenem Resistant Acinetobacter Baumannii (CRAB); a multi drug resistant organism. The ICP reviewed the log of cases for July, August, September, and three weeks of October, 2012. She verified that the facility had a total of 7 cases for these months. The log was compared to the facility's laboratory log of reported cases to the Volusia County Health Department for the same dates. The total count was 14. The housewide infection control monitoring and line list of CRAB infection for the MDRO was not correct.

3. Reports from the local health department revealed that the hospital had continued to have CRAB and MDRO infections, and have not followed a plan to implement the recommendations of the epidemiologists, which included: initial surveillance screening cultures on admission to special at risk units, maintain an electronic line list of all patients infected or colonized with CRAB on a daily basis and report weekly to the health department, and to ensure adequate staffing of Infection Control Preventionists.

4. Patient #31 may have contracted the CRAB, MDRO, and is documented as "HA" (hospital acquired). The patient did receive sputum and blood cultures on 9/14/12 (admission), which were negative. On 10/14/12, the blood tested positive for CRAB, and the sputum positive for Methycillin Resistant Staphylococcus Aureus (MRSA).

5. Further interview of the contracted Infection Control Preventionist on 10/23/12 noted the hospital had one additional Registered Nurse assigned to the infection control program and was planning to hire an Infection Control Preventionist. Additionally, there was no admission surveillance program for MDRO, which includes CRAB. The ICP stated that she was aware that this is not in accordance with CDC guidelines (MDRO, 2006).

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Based on observations, interviews, and review of the infection control log of Acinetobacter infections for the months of July, August, September, and October, 2012, the hospital does not have a monitoring system of the multi drug resistant organism of Carbapenem Resistant Acinetobacter Baumannii (CRAB). The Infection Control Preventionist's log was incomplete for 7 of the 14 cases for the past three months. Additionally, the log may have documented positive "house acquired" cases which were actually "admitted with", due to the lack of an admission screening surveillance program.

The findings include:

1. Review of the Infection Control log with the Infection Control Preventionist (ICP) was conducted on 10/24/12, at 11:00 AM. Seven cases were identified on the Acinetobacter log as CRAB. After reconciling the log with lab reports and the county health department reports, 14 cases were identifed for the 3 month period. The ICP stated that she may not have been given all of the results due her limited computer access.

2. Patients listed to have hospital acquired CRAB did not receive screening cultures on their admission dates.

Patient #1 was admitted on 6/18/12, sputum and blood positive on 7/11/12.

Patient #4 was admitted on 8/4/12, decubitus ulcer positive on 8/10/12.

Patient #5 was admitted on 7/24/12, bronchial washing and urine positive on 8/11/12.

Patient #6 was admitted on 8/5/12, sputum positive on 8/23/12.

Patient #10 was admitted on 8/17/12, sputum positive on 9/19/12.

Patient #13 was admitted on 9/27/12, urine positive on 10/4/12.


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Based on review of the infection control policy manual, infection control logs, reports from the local health department epidemiologists, and interviews with the Nursing Manager, Infection Control Preventionist (ICP), Chief Nursing Officer, and Quality Director, the hospital administration has failed to implement a plan to eliminate the ongoing Carbapenem Resistant Acinetobacter Baumannii Infections, a multi drug resistant organism (MDRO).

The findings include:

1. A review of the Infection Control and Prevention Manual, Infection Control Surveillance, dated 9/18/12, was conducted with the ICP on 10/23/12 at 2:00pm. The policy states that surveillance is under the direction of the Infection Control Committee. The committee approves the surveillance plan annually. When asked which patients are screened for MDRO on admission or routinely, she responded only complicated surgery patients are pre-tested. Further, she stated that the committee has not approved any admission screening of special populations as recommended by the Centers for Disease Control (CDC) or the local health department. When asked which national guidelines the hospital infection control program is based on; she responded that she utilizes the CDC, and The Association for Professional in Infection Control (APIC).

2. Interview of the Medical Intensive Care Unit Nurse Manager, on 10/23/12, confirmed that there was no screening for MDRO of admissions from nursing homes, homeless, or any special risk populations. The manager stated that she was aware of the CDC 2006 guidelines for MDRO screening and the local health department's recommendations. She stated that her nurses have to ask each patient's physician for a culture or it may not be ordered. There is no admission surveillance testing for any patients currently.

3. Information from the County Health Department to the hospital in July 2012 outlines that the facility has not followed a plan to eliminate the carbapenem resistant acinetobacter baumannii, MDRO.

4. Interview of the Quality Director, Chief Nursing Officer, and Risk Manager on 10/23/12, at 9:00 AM, confirmed that the facility had not developed an initial screening or set criteria for screening of any patients upon admission. The CNO stated that the plan was to hire an ICP to lead their infection control program but to date, the position was not filled and was being provided by contract.

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