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Based upon review of the personnel file of the Infection Control Registered Nurse (RN), and staff interviews, the hospital failed to ensure the designed infection control RN maintained and had current education relative to infection control practices, education and training. Findings:

Review of S3 Infection Control RN's personnel file revealed she was designated as the hospital's Infection Control/Employee Health Nurse on August 1, 2005. Review of the job description for Infection Control revealed: "JOB SUMMARY: Responsible for the daily management of infection prevention and control activities...Develops a system for identifying, reporting, investigating, and controlling infections and communicable diseases..."

Review of S3's education relative to Infection Control revealed on 04/15/2010 she received a training certificate from the Louisiana Department of Public Health for a course titled "Healthcare Associated Infection Statistics"; her next training was documented 05/20/2010 for an APIC (Association of Professionals in Infection Control) webinar for 1 contact hour. Further review of S3's personnel file revealed "SUPERVISION: Received From: Director of Performance Improvement (This RN has a Microbiology Degree)"; however there failed to be documentation of such supervision other than the annual evaluation. There lacked documented evidence S3 sought guidance from this RN; and there failed to be documented evidence S3 had infection control training and education other than the two courses above.

Review of S3's annual evaluation form, dated 08/02/2011, revealed she was to: "2.0 Conduct ongoing infection control surveillance; compile and interpret surveillance data...6. Institute and maintain records and data pertinent to all assigned environmental and patient surveillance monitoring systems..."

Interview, on 06/07/12 at 10:00AM, with S3 RN Infection Control Nurse confirmed beside the 2 listed courses in the above paragraph she lacked on-going, current training and education in infection control.

Based upon review of the hospital's Infection Control Plan/Policies and Procedures, and staff interview the hospital failed to ensure the Infection Control Nurse followed the hospital's established Infection Control Plan/Policies and Procedures as evidenced by: 1) failure of the Infection Control Registered Nurse (RN) to track/trend, investigate and report all infections by lack of documented evidence that all surgical site infections were monitored, and 2) failure to maintain a surveillance log of all infections. Findings:

Review of the hospital's Infection Control Policies and Procedures revealed: "Function: Surveillance, Prevention, and Control of Infection (IC) Subject: INFECTION CONTROL PLAN Department: Infection Control Scope: Hospital-Wide...Statement: ...In addition to reporting isolation cases, suspected infections and positive cultures, as well as providing required follow-up information, each department will be responsible for full and timely cooperation with the Infection Control Committee/Infection Control Coordinator to develop and implement remedial/corrective action....To coordinate the infection control activities, infection control management functions are delegated to the Infection Control Coordinator/Infection Control Committee to investigate and follow-up on clinical issues..."

Review of the data collected by S3 revealed she failed to document all possible infections as evidenced by a lack of monitoring for the procedures performed in the Pain Management Unit by S18 Anesthesiologist.

Interview, 06/07/2012 at 10:00am, with S3 RN Infection Control Nurse revealed she did not monitor the surgical procedures/spinal injections performed by S18. When questioned why these surgical/injections were not monitored, S3 did not reply.

During an interview, 06/07/12 at 11:20am, with S2 CNO it was verified that the surgical site infections for the Pain Management Unit were not being monitored and tracked. S2 confirmed there lacked documented evidence S3 was collecting data to track and trend all surgical site infections for procedures performed in the hospital.

Review of the information/data relative to the hospital's Infection Control Plan/Program revealed the Infection Control RN failed to maintain a list of all cultures and sensitivities (C&S) performed on all inpatients as evidenced by a lack of knowledge of 21 of 21 patients who were admitted in March 2012 and were found to have infections with various organisms besides the organisms she monitored. Further review of the Infection Control Plan revealed the data collection was performed quarterly.

Interview, on 06/05/12 at 10:30AM, with S3 Infection Control RN revealed when questioned if she maintained a log of all infections reported as a result of cultures and sensitivities (C&S), that were ordered on inpatients, she replied the only organisms she monitored were MRSA, C. diff., and VRE (Methicillin Resistant Staphylococcus aureus, Clostridium difficile, Vancomycin Resistant Enterococcus).

There failed to be documentation S3 Infection Control RN had conducted active surveillance and was tracking, trending, monitoring, investigating and reporting incidents relative to infection control.

Based upon reviews of the Hospital's Infection Control Plan/Program and data, list of cultures and sensitivities performed by the laboratory for March 2012, and staff interviews, the hospital failed to ensure the Infection Control Registered Nurse (RN) maintained and kept current a log of all incidents related to infections as evidenced by 1) a lack of documented surgical site infections that included the procedures performed in Pain Management; and 2) a review all patients presenting with or those who developed hospital associated infections evidenced by 21 of 21 patients (who were admitted and discovered to have various infections), with one patient (#5) who was admitted and subsequently developed an infection in his sputum; however, review of the data presented by Infection Control failed to capture this infection. Findings:

1) Review of the hospital's Infection Control Policies and Procedures revealed: "Function: Surveillance, Prevention, and Control of Infection (IC) Subject: INFECTION CONTROL PLAN Department: Infection Control Scope: Hospital-Wide...Statement: ...In addition to reporting isolation cases, suspected infections and positive cultures, as well as providing required follow-up information, each department will be responsible for full and timely cooperation with the Infection Control Committee/Infection Control Coordinator to develop and implement remedial/corrective action....To coordinate the infection control activities, infection control management functions are delegated to the Infection Control Coordinator/Infection Control Committee to investigate and follow-up on clinical issues..."

Review of the data collected by S3 failed to document all possible infections as evidenced by a lack of monitoring for the procedures performed in the Pain Management Unit by S18 Anesthesiologist.

Interview, 06/07/2012 at 10:00am, with S3 RN Infection Control Nurse revealed she did not monitor the surgical procedures/spinal injections performed by S18. When questioned why these surgical/injections were not monitored, S3 did not reply.

During an interview, 06/07/12 at 11:20am, with S2 CNO it was verified that the surgical site infections for the Pain Management Unit were not being monitored and tracked. S2 confirmed there lacked documented evidence S3 was collecting data to monitor, track and trend surgical site infections for all procedures performed in the hospital.

2) Review of the information/data relative to the hospital's Infection Control Plan/Program revealed the Infection Control RN failed to maintain a list of all cultures and sensitivities (C&S) performed on all inpatients as evidenced by a lack of knowledge of 21 of 21 patients who were admitted in March 2012 and were found to have infections with various organisms besides the organisms she monitored. Further review of the Infection Control Plan revealed the data collection was performed quarterly.

Interview, on 06/05/12 at 10:30AM, with S3 Infection Control RN revealed when questioned if she maintained a log of all infections reported as a result of cultures and sensitivities (C&S), that were ordered on inpatients, she replied the only organisms she monitored were MRSA, C. diff., and VRE (Methicillin Resistant Staphylococcus aureus, Clostridium difficile, Vancomycin Resistant Enterococcus).

A list of patients was obtained from the laboratory. The surveyor requested S6 Laboratory Director to print a list of all C&S testing performed for the month of March 2012. Review of the list revealed 21 patients were admitted and had C&S studies performed with 21 of 21 positive cultures for various organisms excluding MRSA, VRE, and C. diff (the only 3 organisms S3 stated she tracks). The patients who were examined and treated in the Emergency Department and all Outpatients were not included in this review. (Except when the patient was admitted from the Emergency Department, then they were included in the count.)

Review of patient #5's medical record revealed he was admitted on 03/15/2012 with Congestive Heart Failure. Review of a laboratory report revealed a sputum C&S was performed on 03/20/12; the results were dated 03/23/12 and indicated his sputum was positive for infection with E.(Eschericia) coli. Continued review revealed on 3/30/12 a C&S was performed on drainage from his eye; the results were dated 04/03/12 and indicated an infection with E. faecalis (Enterococcus faecalis) and S. maltophilia (Stenotrophomonas maltophilia-is ubiquitous in water environments, soil and plants; it is naturally resistant to many broad-spectrum antibiotics). A urine C&S was performed on 03/15/12 and results on 03/18/12 indicated infection with E. faecalis.

Follow up interviews, on 06/07/12 at 11:30AM, with S2 Chief Nursing Officer (CNO), S3 Infection Control RN, and S15 RN Utilization Review/Infection Control (working in infection control for past 2 weeks), confirmed S3 Infection Control RN had not maintained a log that captured all inpatient infections. Again, this was evidenced by the failure to identify patient #5 as having acquired a hospital associated infection (positive sputum culture). The surveyors stopped the review of records as S3 stated she had not reviewed any other infections other than MRSA, VRE, and C. diff. It was also identified S3 was not monitoring, tracking and trending all surgical site infections.