HospitalInspections.org

Based on record review and interviews with hospital staff, the hospital does not ensure the hospital's pharmaceutical services oversee all the drugs and medications in all hospital locations including the surgical suite. The hospital's pharmaceutical services do not check the drugs and medications stored in the surgical area for outdates, unusable drugs and scheduled drug inventory. This was verified by the Drug Room Supervisor on 05/14/14 in the afternoon.

Based on infection control meeting minutes review, infection control policy and procedure review, personnel file review, and staff interview, the hospital failed to have an active, ongoing system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.
Findings:
1. There was no documentation that all the disinfectants used throughout the hospital had been reviewed and approved by the infection control practitioner and the medical staff.
2. On the afternoon of 05/13/2014, Staff M told the surveyors that she thought the disinfectants had been approved in 2008. No documentation was provided.
3. There was no documentation of regular environmental rounds done by the infection control practitioner. Staff M told surveyors that she does make environmental rounds but doesn't document it.
4. There was no documentation of that employee illnesses and hospital acquired illness had been investigated. Staff M told surveyors that Staff D was the employee health nurse.
5. On the afternoon of 05/14/2014, surveyors observed surgical scrubs stored in employee personal lockers with personal items brought from home. The personal lockers were opened.
6. Twenty of twenty personnel files reviewed contained no documentation that the staff had been given infection control training on hire and annually. A hospital policy, titled, "Orientation/Inservice",documented, "...all new staff members will be oriented to the Hospital's Infection Control Program. All patient care staff members will be inserviced at least annually on infection control practices specific to their clinical area..."
7. On the afternoon of 05/13/2014, Staff M told surveyors that she did not provide infection control training to the staff.