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Based on interview and record review, the Infection Control Preventionist did not implement and evaluate measures as required by the facility's policy for identifying, reporting, investigating, and controlling infection for 1 of 1 patient (Patient #1) who was readmitted on 08/18/10 for possible right shoulder infection.

Findings include:

Patient #1 was initially admitted and discharged on 06/17/10 for a scheduled "right shoulder arthroscopic repair of ...rotator cuff tear ..." The patient presented in the ER (Emergency Room) for right shoulder pain on 08/14/10. The physician's orders dated 08/18/10 at 12:00 PM included "admit to Physician #6, diagnosis: right shoulder infection S/P RTC repair...Plan to OR (operating room)...for I&D (Irrigation & Debridement) of right shoulder..." Samples were obtained for culture and sensitivity. The final laboratory test results on 08/25/10: "Subacromial bursa culture...aerobic=heavy growth of "Citrobacter Freundii Complex."

Computer data entry of Infection Control records: "HAI-POA Line List" (Hospital Acquired Infection - Present on Admission) dated August 2010 included that Patient #1's prior visit was on 06/17/10. The patient was readmitted on 08/18/10 for "re-injury" and not for a possible right shoulder infection.

In an interview on 03/03/11 at approximately 11:30 AM in the presence of Personnel #1, Personnel #5 was asked if the infection acquired by Patient #1 since being admitted to the hospital on 08/18/10 was documented and tracked. She replied that it was not documented as an infection but a "re-admit due to re-injury." She was asked if she knew that part of the procedure performed on 08/18/10 was an "I&D" and that samples were obtain to rule out infection. She replied the infection was not documented and tracked. The CEO stated that "I&D's" was an indicator of infection.

Policies and Guidelines #2: "Infection Prevention & Control Plan" revised Sept 2010 page 1 required "The Infection Prevention & Control plan ...includes the following: 1. Patient population served by the facility ...5. Strategies to reduce risks ..." On page 2 "2010-2011 Infection...Program Goals...4. Surveillance of infection with physician follow-up."

Policies and Guidelines #11: "Surveillance" revised Dec 2010 required "Surveillance will be systematic and continuous process for the recognition, monitoring, and reporting of infections ...The Infection Preventionist and Quality personnel ...are responsible for data collection ..."