HospitalInspections.org

Based on policy and procedure review, personnel record review, and staff interview, the infection control officer failed to ensure regular training updates in preventing and controlling healthcare-associated infections and methods to prevent exposure to and transmission of infections and communicable disease as required by facility policy and procedure for 11 of 13 (P1-P3, P5, P6, and P8-P13) personnel records reviewed.

Findings:
1. Policy titled, "Infection Control - Employee Education and Training Procedures" was reviewed on 4/17/12 at approximately 1:25 PM, and indicated on pg. 1 of 1, under Procedure section and point:
A. 1. "The Safety/Infection Control Committee, in conjunction with Human Resources and accreditation staff, will identify, plan, coordinate, and provide education and training to all staff at orientation and yearly training for those staff at greater risk of coming in contact with blood-borne pathogens. 1) All employee training will be conducted prior to initial assignment to tasks where occupational exposure may occur and annually thereafter.
B. 2. Training will include: a) Epidemiology and symptomatology of blood-borne diseases. b) Modes of transmission of blood-borne pathogens. c) Signs and labels used at [facility] for hazardous material. d) Accessibility to the Infection Control Policy.
C. 3. Training will be conducted by use of on-line courses, videotape, and printed material. Training will be provided by the Safety/Infection Control Committee, Human Resources or the Management Team."

2. Review of personnel records at 9:30 AM on 4/17/12, indicated personnel P1-P3, P5, P6, and P8-P13 provide direct patient care and lacked documentation of annual training related to infection control for 2011 and/or 2012 to present.

3. Personnel P17 was interviewed on 4/17/12 at 11:03 AM, and confirmed personnel P1-P3, P5, P6, and P8-P13 provide direct patient care and lacked documentation of annual training related to infection control, including Universal Precautions and Blood-borne Pathogens for 2011 as required by facility policy and procedure.