HospitalInspections.org

Based on document review and interviews, the hospital failed to designate the infection control officer and maintain an infection control log for all incidents that are related to infections and communicable diseases, including those that are identified through employee health services. These deficient practices may result in the hospital infection control program's inability to recognize infections or communicable diseases that provide a risk to patients, visitors and staff. The findings are:

A. On 05/31/12 at 4:15 pm, during interview, the infection control practitioner was not aware if she had been designated as the infection control officer by the governing board.

B. On 05/31/12 at 4:50 pm, during interview, the Administrator stated that he had talked about the infection control officer designation at the governing board meeting, but that nothing was documented.

C. On 05/31/12 at 4:15 pm, during interview, the infection control practitioner stated that she does not keep an infection control surveillance log of hospital patients or hospital personnel at this time. She further stated that just because she is not using a log, does not mean that she is not reviewing positive cultures, then determining if the infection is hospital acquired or not.

D. Review of the hospital's policy (undated) titled "Infection Control Committee Methods of Surveillance" revealed the following under "Employees":
"Information is obtained from the Nursing Office regarding nursing personnel reporting ill, department managers reporting personnel ill, Clinical Laboratory Department microbiology results regarding personnel, the Employee Health Nurse and the Public Health Department.
The risks of infection should be prioritized, based on the facilities' demography of patients, the community environment and the services provided. These risks should be assessed as an ongoing process...
Surveillance activities are based on assessed prioritized risks with the goal of preventing the development of healthcare associated infections."

Based on document review and interview the hospital failed to have an arrangement with an outside entity to review the appropriateness of the diagnosis and treatment provided by each Medical Doctor/Doctor of Osteopathy (MD/DO) providing services to the hospital's patients. The failure of the hospital to have an outside entity evaluate the patient care services provided by the medical staff increases the probability that a physician could be providing substandard quality of care to patients. The findings are:

A. During interview on 05/31/12 at 3:15 pm, the Quality Manager was asked to provide evidence that the hospital had an arrangement with an outside entity to review the appropriateness of the diagnosis and treatment provided by each Medical Doctor/Doctor of Osteopathy (MD/DO) providing services to the hospital's patients. She stated, "No, we do not have an agreement to have an outside evaluation done on the care provided by our medical staff." She further stated, "We do have peer review of all of our medical staff's work done by other members of the medical staff." She also added that the hospital uses the Quality Improvement Organization (QIO) when there is a question about care or when the QIO requests a medical record.

B. On 06/01/12 at 10:00 am, the Quality Manager was asked to identify the last time that the hospital had sent out a chart for external review to resolve an issue of care provided by a member of the medical staff. She stated, "The last time we sent a chart out for external review was in late 2009." In other words, no outside review of care provided by members of the medical staff had been done in the last two and a half years.