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Based on record review and staff interview, the Critical Access Hospital (CAH) infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control precautions for 1 of 1 patient ' s sampled (#18) with a open wound on the left hand.

Findings include:

- The CAH ' s Infection Control " Guidelines for Isolation Precautions " dated " 6-1-2009 " , reviewed on 4/28/11 directs staff to use " contact precautions, (visitors are instructed to report to the nurses ' station before entering the patients private room, gowns, mask and gloves must be worn) for patients known or suspected to be infected or colonized with infections that can be transmitted by direct contact with the patient or indirect contact with environmental or patient care items in the patient ' s environment. "

- Patient #18's medical record reviewed on 4/26/11 revealed an admit date of 10/19/10 from a nursing home facility with a diagnosis of a open hematoma on the back of the left hand. The " Comprehensive Admission Assessment " dated 10/19/10 described the wound as, " opened one inch with packing in it oozing some blood. The dressing was soaked at admission. " On 10/24/10 nursing staff continued to note in the daily documentation of the wound increasing in size, redness and became foul smelling. On 10/24/10 the physician ordered the wound cultured and ordered patient #18 transferred to a higher level of care. On 10/28/10 the laboratory report revealed the 10/24/10 culture resulted in a positive culture for Methicillin Resistant Staphylococcus Aureus (MRSA-a highly drug resistant variety of a staph bacterium). Patient #18 ' s medical record lacked evidence the CAH implemented open wound and isolation precautions for a patient admitted with a draining open wound.

Staff A interviewed on 4/26/11 at 1:30pm acknowledged the CAH failed to culture the open wound at admission or implement contact and isolation guidelines for open wound care for a suspected patient with an infection.

Staff B, infection control officer, interviewed on 4/27/11 at 1:00pm acknowledged patient #18 ' s open wound at admission " fell through the cracks " . Staff B confirmed the CAH failed to follow Infection Control isolation and contact guidelines for providing open wound care.




21997

Based on medical record review, staff interview, policy and procedure review the Critical Access Hospital (CAH) failed to ensure staff notified the Organ Procurement Organization (OPO) after 1 of 2 patients expired (# 30).

Findings include:

Policy procedure review on 4/26/11 of the Organ, Tissue, and Eye Donation revealed the procedure is the CAH will refer deaths of all patients to the Midwest Transplant Network Donor Referral Network.

Patient #30 medical record reviewed on 4/26/11 revealed an admission date of 1/31/11 with a diagnosis of cerebral vascular accident (CVA) and end of life care. The patient expired on 2/5/11 medical record lacked evidence the CAH notified the Midwest Transplant Network.

Administrative staff B interviewed on 4/26/11 confirmed patient #30's medical record lacked the OPO notification form.