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Based upon record review and interview, the hospital failed to ensure 1) appropriate signage was present on the door for a patient who was on contact precautions, and 2) the designated individual responsible for the Infection Control Program was qualified by education and/or experience. Findings:

1) During the environmental tour on 11/06/17 at 11:00 a.m. supply carts which contained Personal Protection Equipment (PPE) were present outside of room #124; however, there was no signage on the door which indicated the precautions that were to be implemented when providing patient care. Interview with S4RN/DON revealed when asked what the carts were for she replied the patient was on contact precautions. When asked if it was hospital policy to have contact precaution signage on the door, she replied "yes".

2) Interview on 11/08/17 at 10:00 a.m. with S4RN/DON revealed she was the designated Infection Control Officer. Review of the personnel file for S4RN/DON revealed there was no information related to this position. Further interview with S4RN/DON revealed she had not received any education nor had experience in the principles and methods for infection prevention and control.

Based on record review and staff interview, the CAH failed to ensure all medications were administered in accordance with physician's orders and accepted standards of practice for 1 (#19) of 4 patients reviewed for medication administration out of a total sample of 20 patients.
Findings:

Review of the record for Patient #19 revealed an admission date of 10/23/17 with a diagnosis of infected sacral decubitus. The record revealed the patient was admitted with a PICC line. Review of the admission physician orders dated 10/23/17 revealed orders to clean sacral decubitus with wound cleanser, fill with betadine moistened kerlix, and cover with dressing twice a day. Further review of the admission orders revealed an order to follow PICC line protocol.

On 11/07/17 at 2:00 p.m., review of Patient #19's electronic medical record with S4DON revealed no documented evidence that the patient's sacral decubitus was cleaned and the dressing changed twice daily per physician orders on the following dates:
10/24/17, cleaned/dressing changed one time
10/26/17, no evidence of any cleaning/dressing changes
10/27/17, cleaned/dressing changed one time
10/31/17, no evidence of any cleaning/dressing changes
11/01/17, cleaned/dressing changed one time
11/03/17, cleaned/dressing changed one time
11/05/17, cleaned/dressing changed one time
11/06/17, no evidence of any cleaning/dressing changes

On 11/07/17 at 2:15 p.m., interview with S4DON confirmed that the patient's sacral decubitus was not cleaned and the dressing changed twice daily as ordered by the physician.

Review of the hospital's policy and procedure titled, PICC/Midline, revealed that the PICC line lumens were to be flushed with 2.5mL of Heparin every shift.

Further review of Patient #19's medical record on 11/07/17 at 2:20 p.m. with S4DON revealed no documented evidence that the PICC line lumens were flushed with 2.5mL of Heparin every shift. Interview with S4DON at that time confirmed that there was no evidence that the patient's PICC line was flushed per hospital protocol (every shift).