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Based on interview, record review and review of the facility's policy and procedures, it was determined the facility failed to ensure policies were implemented and governed the control of infections throughout the facility. The facility failed to provide documented evidence that patients with an active infection, were appropriately followed through the surgical areas without exposing all other patients.

The findings include:

Review of the facility's policy entitled, "Infection Control; Isolation Plan", dated 10/07/02, revealed patient placement for Standard Precautions, a private room is recommended for patients who contaminate the environment or those who do not, or cannot, be expected to assist in maintaining appropriate hygiene or environmental control. If a private room is not available, the nursing coordinators are consulted regarding assignment. Further review revealed for patients on Contact Precautions, in addition to standard precautions, use contact precautions for specified patients known or suspected to be infected or colonized with epidemiological important microorganisms. Diseases in this category are transmitted by direct contact with the patient (hand or skin to skin contact occurring during performance or patient care activities that require touching the patients dry skin), or indirect contact with environmental surfaces or patient care items in the patient's environment. Further review of the policy revealed examples of such illnesses include: Methicillin-Resistant Staphylococcus Aureus (MRSA), Vancomycin Resistance Enterococcus (VRE), Clostridium difficile (C. difficile), Respiratory Syncytial Virus (RSV), Parainfluenza, Scabies, Lice, Impetigo. Continued review revealed patient placement would be in a private room when available and when a private room is not available, place the patient in a room with a patient who has active infection with the same microorganisms, but with no other infection.

Interview with Registered Nurse (RN) #1, Infection Control Nurse, on 04/12/12 at 8:30 AM, revealed the facility had a tracking and trending system for patients with active infections. However, the facility did not have a system for tracking patients with infections as they moved through the facility such as to and from the surgery area. Further interview revealed there was no documented evidence the facility placed patients with infections in designated areas to prevent and/or reduce the transmission of diseases or infections in the hospital.

Interview with RN #2/Nurse Manager of the Surgical Unit, on 04/12/12 at 12:00 PM, revealed the surgery area had specific rooms that were utilized for patients with infections. Further interview revealed the surgery area used the end room for any patient that had an active infection. Continued interview revealed, the facility could not provide any documented evidence the the designated room was utilized for patients with infections.

Record review of five (5) medical records of patients that had infections (Patients #1, #2, #6, #7 and #10), revealed no documented evidence the facility utilized the designated room in the surgery area for these patients.

Interview with the Director of Nursing, on 04/12/12 at 3:00 PM, revealed patients with infections should be monitored through the surgery area to prevent additional contamination. Continued interview revealed, it was her understanding certain areas were used for those patients that had infections.

Interview with RN #1/Infection Control Nurse, on 04/13/12 at 10:15 AM, revealed the facility did not have a process in place to monitor patients with infections through the same day surgery area or patients scheduled for a surgical procedure. Further interview revealed the facility could provide no documented evidence patients with infections were isolated, in order to prevent cross contamination, by utilizing the designated room because the facility documentation did not indicate which room a patient utilized either before or after the surgical procedure.