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Based on the certification survey completed on 6/6/12, the facility was found not in compliance with Life Safety from Fire found at CFR 485.623(d).

Refer to Life Safety Code deficiencies; K050, K052, K056, K061, K076- for additional information.

The cumulative effect of these systemic problems resulted in the Critical Access Hospital's inability to ensure safety from fire therefore they were unable to meet this condition.

Based on observation, interview, and document review, the CAH (Critical Access Hospital) failed to ensure the infection control program was being implemented related to ongoing monitoring and trending of infection rates from the surveillance program according to the established policies. This practice had the potential to effect all patients who were treated at the CAH.

Findings included:

On 6/5/12, at 1:45 p.m. Registered Nurse (RN)-A the infection control lead, stated that the CAH had not identified incidence of hospital acquired infections and therefore could not have identified patterns and trends or completed surveillance related to hospital acquired infections. RN-A verified she did not have hospital-acquired infection rates for the CAH from the past year.

Review of the infection control logs from 3/1/12-6/4/12, revealed that the CAH had multiple incidence of infections that included: Fever (5 incidents), pneumonia (16 incidents), urinary tract infections (7), that were identified on the log, however there had been documentation of investigation which determined if the infection was hospital acquired, or if the signs and symptoms were related to the admission diagnosis, signs and symptoms developed during the stay, type of infection, culture sensitivities, and antibiotics used.

Review of the Infection Control Committee Policy last reviewed 5/06, identified the following "3. The committee will assess the effectiveness of the Hospital Infection Control Program by reviewing the following reports: a. Monthly and year to date Infection Surveillance reports to determine: 1. Nosocomial Infection 2. Nosocomial infection rate b. Nosocomial infection rate by area. c. Antimicrobial usage on patients with nosocomial infections. d. Employee Health Report e. Microbiologic sampling report. f. Yearly antibiograms report..."

The Director of Nursing services was interviewed on 6/6/12, at 10:15 a.m. during which she confirmed that the CAH had not followed its infection control policy and had not identified incidence of hospital acquired infections and identified patterns and trends related to hospital acquired infections.

Based on review of the Critical Access Hospital (CAH) Annual Review and interview, the CAH had not conducted a review of the infection control policies as part of the annual evaluation. Findings include:

The facility failed to ensure policy and procedure review of the infection control program was conducted by the CAH Annual Review committee.

Review of the "Infection Control Committee Policy" identified that it was last reviewed and revised by the CAH annual review committee on "5/06". During review of the policy the following was identified: "7. The committee will review the policies and procedures of the Infection Control Program every year."

The Director of Nursing (DON) was interviewed on 6/6/12 at 10:15 a.m. during which she confirmed that the CAH infection control policies had not been reviewed since 5/06.

Based on observation, interview, and document review, the CAH (Critical Access Hospital) failed to ensure the quality assurance commitee had reviewed nosocomial infections and medication therapy. This practice had the potential to effect all patients who were treated at the CAH.

Findings included:

On 6/5/12, at 1:45 p.m. Registered Nurse (RN)-A the infection control lead, stated that the CAH had not identified incidence of hospital acquired infections and therefore could not have identified patterns and trends or completed surveillance related to hospital acquired infections. RN-A verified she did not have hospital-acquired infection rates for the CAH from the past year.

Review of the infection control logs from 3/1/12-6/4/12, revealed that the CAH had multiple incidence of infections that included: Fever (5 incidents), pneumonia (16 incidents), urinary tract infections (7), that were identified on the log, however there had been documentation of investigation which determined if the infection was hospital acquired, or if the signs and symptoms were related to the admission diagnosis, signs and symptoms developed during the stay, type of infection, culture sensitivities, and antibiotics used.

Review of the Infection Control Committee Policy last reviewed 5/06, identified the following "3. The committee will assess the effectiveness of the Hospital Infection Control Program by reviewing the following reports: a. Monthly and year to date Infection Surveillance reports to determine: 1. Nosocomial Infection 2. Nosocomial infection rate b. Nosocomial infection rate by area. c. Antimicrobial usage on patients with nosocomial infections. d. Employee Health Report e. Microbiologic sampling report. f. Yearly antibiograms report..."

The Director of Nursing services was interviewed on 6/6/12, at 10:15 a.m. during which she confirmed that the CAH had not followed its infection control policy, had not identified incidence of hospital acquired infections and related medication therapy and therefore could not have reported incidence of nosocomial infection and medication usage to the quality assurance committee.