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Based on interview, document review, and policy and procedure review, the provider failed to develop and implement a hospital wide comprehensive infection control program. Findings include:

1. Interview on 5/31/16 at 3:05 p.m. with the infection control coordinator (ICC) regarding the infection control program revealed:*She had been the ICC for approximately four years.
*The nursing staff attempted to complete thirty hand hygiene audits monthly for compliance of that procedure.
*She gathered that information as well as any known infections during each month for antibiotic-resistive infections such as:-Methicillin-resistive infections.
-Vancomycin-resistive infections.
-Clostridium difficile infections.
*She also monitored for hospital acquired catheter associated urinary tract infections.
*The director of nursing (DON) brought that data to the medical staff meeting monthly for review.
*When questioned about previous infection control auditing she stated she had only audited hand washing.
*She stated infections other than those on the list above were not monitored for tracking and trending, because the patient census was normally low which did not allow for cross-contamination.
*The clinic registered nurse (RN A) was the employee health nurse.
*The ICC did not take part in monitoring the employee health program.
*She received initial training for hospital infection control in 2012.
*She had some infection control training with the corporate office during the spring and fall infection control meetings.

Interview on 5/31/16 at 4:15 p.m. with the employee health nurse regarding her role with employee infection control revealed:
*She only provided tuberculin testing and flu shots to the employees.
*She had not reviewed the employee illnesses.
*The DON kept track of employee illnesses.

Interview on 6/2/16 at 9:00 a.m. with RN A revealed:*She assisted the physician monthly with endoscope procedures.
*She called the patients on the day after the endoscope to ask about symptoms of infection.
*She had not called again at a later time to verify any infections or concerns.
*She had not attended infection control meetings.

Interview on 6/2/16 at 9:15 a.m. with the director of central supply revealed:*She assisted with the endoscope procedures.
*She had not attended infection control meetings.

Review of the July 2015 through May 2016 Quality Assurance (QA) Meeting minutes revealed:
*Each month's meeting minutes had stated infection control information had been reviewed in the quality indicator report.
*No infection control information had been presented on the performance improvement report.

Interview on 6/2/16 at 12:25 p.m. with the DON revealed:
*She had just recently become aware the ICC was not doing her job regarding infection trending and employee health.
*The ICC was to have gathered the infection control information.
*The DON had expected the ICC to present infection control information at the monthly medical staff and QA meetings.
*Neither the DON nor anyone else had presented the infection control information at the monthly medical staff or QA meetings.
*She was unable to locate any infection control meeting minutes and had discovered no infection control meetings had occurred.
*She had sent several emails to the ICC to get her involved in presenting infection control information to the nursing staff, but the ICC had not responded.
*She stated the ICC had not participated in further infection control education since 2014.
*She had not discovered the extent of the ICC problems until 5/13/16 when it became clear the employee health program was not functioning. At that time she notified the corporate office for their assistance.
*She had received the employee illness slips and placed them in the employee files but had not logged those illnesses for tracking.
*She had not involved the ICC upon receipt of the illness slips.

Interview on 6/2/16 at 2:00 p.m. with the DON and interim chief executive officer revealed:
*They agreed the infection control program needed to report surveillance data to the QA committee and the leadership committee. *They had not realized infection control information was not reviewed by the QA committee.
*The previous DON had presented the infection control information herself, so she had not needed to deliver the information to the QA leader before each meeting.
*There was no job description for the infection control coordinator.

Review of the provider's 6/22/15 Medical Staff Bylaws, Rules and Regulations revealed:
*The infection control committee would consist of active medical staff members, the hospital administrator, all department heads, and the infection prevention director.
*The committee would meet quarterly.
*The committee would recommend plans for maintaining infection prevention measures.
*The committee would submit regular reports to the medical staff and board of directors on infection prevention measures and infection prevention activities conducted.

Review of the 6/30/15 Infection Control policy/procedure revealed:*Effective measures were to have been developed to identify, control, and prevent infections.
*A multidisciplinary infection control committee was established to direct an infection control program.
*The medical staff and the department head committees were to be a part of the program.
*Goals and objectives had included:-Providing an analytic review of surveillance data and implementing effective control measures and appropriate follow-up action.
-Providing periodic review and evaluation of infection control techniques as well as monitoring effectiveness of sterilization and disinfection practices.
-Providing input into the scope and surveillance of the employee health program.
-Reviewing and approving results of all special studies relative to infection control.

Review of the provider's 6/30/16 Employee Health Program policy/procedure revealed:*The employee health nurse reviewed all completed pre-employment infection control requirements for abnormal findings.
*Department heads documented the employee illness on an employee health report. The form was to have been forwarded to the ICC.
*Completed employee health reports were to have been utilized/filed as the method of tracking employee illness/communicable disease by the ICC.

Based on record review, interview, and medical staff bylaws, rules, and regulations review, the provider failed to ensure:
*A pharmacy regimen review had been done for one of one sampled patient (1) who had been in the skilled swing bed department for over thirty days.
*A pharmacy and therapeutics committee was developed and held meetings on a quarterly basis.
Findings include:

1. Review of patient 1's medical record revealed:
*She had been admitted to the skilled swing bed department on 12/21/15 and discharged on 2/11/16.
*She had received skilled swing bed services for fifty-nine days.
*No pharmacy documentation to support the pharmacist had completed a review of her chart during the above time frame.

Interview on 6/1/16 at 2:10 p.m. with the temporary pharmacist revealed:
*He had been working two days per week since the full-time pharmacist had resigned less than a month ago.
*He could not locate any documentation to support a pharmacy review had been completed for patient 1 during her skilled swing bed stay.
*He agreed there should have been a pharmacy review and reconciliation report completed on that chart.
*He had not been able to find a policy and procedure on pharmacy reviews.

Interview on 6/1/16 at 3:50 p.m. with the interim chief executive officer revealed:
*She had no documentation to support the pharmacy department had been completing chart reviews for the skilled swing bed patients.
*The provider had no policy or procedure in place for how often a pharmacy review of the patient's charts should have been completed when receiving skilled swing bed services.

2. Interview on 6/1/16 at 2:30 p.m. with the temporary pharmacist revealed:
*He had no documentation to support the pharmacy department had developed a pharmacy and therapeutics committee.
*He had documentation to support the prior pharmacist had attended the medical staff meetings from May 2015 through May 2016.
*He had agreed the pharmacist should have organized a pharmacy and therapeutics committee. That committee should have held meetings on a regular basis.
*He had not been able to find a policy and procedure on pharmacy and therapeutics committee.

3. Interview on 6/1/16 at 4:00 p.m. with the interim chief executive officer revealed:
*She had not been aware the pharmacy department should have developed a pharmacy and therapeutics committee.
*She had no documentation to support the pharmacy department had a committee and met on a regular basis.
*She had documentation to support the prior pharmacist had attended the medical staff meetings from May 2015 through May 2016.
*The provider had no policy and procedure in place for the pharmacy department regarding a pharmacy and therapeutics committee.

Review of the provider's 6/22/15 Medical Staff bylaws, rules, and regulations revealed:
*"The Pharmacy and Therapeutics Committee shall consist of the Pharmacy Medical Director, Hospital Pharmacist, Director of Patient Care Services, and Hospital Administrator."
*"The pharmacy and Therapeutics Committee shall meet quarterly."

18559

Based on quality assurance meeting minutes review, hospital nursing performance improvement (PI) dashboard, job description review, policy review, medical staff bylaws review, contracted services agreement, and interview, the provider failed to ensure a comprehensive, on-going quality assurance program under the direction of a qualified individual for one of one community access hospital. Findings include:

1. Review of the hospital nursing PI dashboard revealed it included the following:
*Clinic:
-Monthly clinic safety and outdated monitoring.
-Documented in the chart within seven days after receiving report.
*Dietary:
-Food temperatures.
-Dietician documented on acute and swingbed patients.
*Clinical safety nursing:
-Nursing unit safety and outdate monitoring.
*Documentation nursing/providers.
-Midlevel documenting that doctor notified of admission.
-Follow-up phone calls.
-Emergency medical treatment and labor act (EMTALA) Form.
*Troponin results received within sixty minutes of arrival.
*Readmissions for overall thirty day readmission.
*Infection control:
-Hand hygiene compliance.
-Health care acquired methicillin-resistant staphylococcus aureaus (MRSA) infection/colonization incidence.
-Healthcare acquired vancomycin-resistant enterococci (VRE) infection/colonization incidence.
-Clostridium.
-Hospital acquired catheter associated urinary tract infections.
*No information was documented from September 2015 through March 2016 for the clinic, dietary, and documentation-nursing/provider.
*No information was documented from November 2015 for dietary and documentation-nursing/provider.

Review of the provider's quality assurance meeting minutes from 10/27/15 through 5/3/16 revealed:
*Infection control quality indicator (QI) reports was on the agenda.
*The hospital nursing PI dashboard was not included in the meeting minutes.
*No documentation to support the skilled swing bed department had been reviewed or was on the agenda.
*No corrective actions documented for 2016.
*No documentation to support the contracted service agreements had been reviewed.

Review of the provider's 6/30/15 quality improvement, utilization review, and skilled swing bed facilitator registered nurse job description revealed the individual:
*Must be a registered nurse in the state of South Dakota.
*Should have coordinated the facility wide improvement programs to include all departments.
*Should have assisted in the screening criteria, data analysis, and problem identification.

Review of the provider's 6/30/15 Swing Bed Policy revealed "Quality Improvement will be monitored and reported to the [provider's name] Quality Program, by assessing patient care and and other support processes in a systematic, on-going manner in order to identify improvement opportunities and act on them in a timely manner."

Review of the provider's contracted services agreements revealed:
*The social services consultant agreement had been reviewed on July 7th. There was no documentation to support what year it had been reviewed.
*The food and nutrition services agreement had not been reviewed since 2/15/06.
*The integrated therapy services agreement had not been reviewed since 6/30/01.
*There had been no contracted service agreement in place for the temporary pharmacist currently on staff.

Review of the provider's 6/22/15 medical staff bylaws, rules, and regulation revealed no documentation to support how often the consulting staff agreements should have been reviewed.

Review of the provider's 6/30/15 quality assurance/performance improvement policy revealed:
*All departments would have been required to have a minimum of one PI project at all times.
*Quality standards and improvement opportunities affecting patient care had been identified, evaluated, and resolved as applicable.
*Departmental PI activities would have been reviewed monthly.

Interview on 6/1/16 at 3:45 p.m. with the interim chief executive officer (CEO) revealed:
*She had not been aware how often the contracted service agreements had been reviewed.
*She agreed the contracted service agreements should have been reviewed with those consultants and providers yearly.
*She confirmed there had been no contracted service agreement in place for the temporary pharmacist.
*The provider had no policy and procedure in place on how often the contracted service agreements should have been reviewed.

Interview on 6/2/16 at 8:45 a.m. with the health information manager (HIM) revealed she would have entered information into the QA dashboard. The information was forwarded to the interim chief executive officer CEO for review.

Interview on 6/2/16 at 9:15 a.m. with the director of nursing (DON) revealed:
*Her and two other nurses had been responsible for the supervision of the swing bed department.
*She had:
-Attended the QA meetings.
-Not been sure if the swing bed department was discussed at those meetings.
-Not been aware the swing bed department should have been reviewed for any issues or concerns at those meetings.
-No documentation to support the swing bed department had identified any improvement opportunities and had discussed those concerns at the above QA meetings.

Interview on 6/2/16 at 2:00 p.m. with the interim CEO and the DON revealed:
*The previous CEO had left in January.
*Quality assurance had been performed by the CEO but was transferred back to the HIM when he left.
*The DON started in her job position in October 2015.
*The previous DON brought the infection control information to the QA meetings.
*The DON was not aware she needed to bring the infection control information to the QA meeting.
*Any corrective actions for information that had not met the benchmark should have been performed at the 5/3/15 QA meeting. None were done.