HospitalInspections.org

Based on interview, document review and observation, the governing body failed to assure the Infection Control Program and Committee was functioning at the required level. Failure to assure the Infection Control Program is functioning places patients at risk for acquiring infections while hospitalized.

Findings include:

Based on interview with the Infection Prevention Committee Physician Chairperson, the committee has not met since the departure of the past IPP in 2014. On committee minutes review, the Infection Control Committee met in February 2105 and July 2015 but without physician leadership chairmanship. To reflect the importance of infection control the regulations specifically require that the hospital's QAPI and training programs must be involved in addressing problems identified by the infection control program, and hold the CEO, medical staff and DON jointly responsible for linking the infection control program with the QAPI and training programs. These requirements were not found at time of survey.

The above information was validated by the Quality Director and apprentice IPP.

Please see Tag 0749.

Based on interview, document review and observation, the hospital failed to maintain an active infection prevention program by a qualified infection prevention professional. Failure to maintain an active infection prevention program places patients at risk of a hospital acquired infection.

Findings include:
PeaceHealth St. John has had a void in the coverage of an assigned infection prevention professional (IPP) to oversee the facility's program since the beginning of 2014. The organization hired an apprentice IPP in July 2015 but at the time of survey this individual did not hold the required credentials as defined by Center of Disease Control (CDC). CDC has defined "infection control professional" as "a person whose primary training is in either nursing, medical technology, microbiology, or epidemiology and who has acquired specialized training in infection control." At the time of survey, the apprentice did not possess the above specific training or credentials.

The hospital did not have a policy designating in writing an individual as its infection control officer. The hospital designated a member of the medical staff to chair the Infection Control Committee but no specific person was designated as the Infection Control Officer.

The hospital is expected to identify and track infections and communicable diseases. At the time of survey, based on interview with the nurse manager of nursing supervisors, the process to place patient's in isolation requires notification to the infection prevention professional. On interview with the apprentice IPP, the information about which patient is currently in isolation is provided on a daily census sheet provided by the nursing supervisor and does not have initial involvement with the IPP.

The Infection Control P&P states that caregivers will consult the IPP when there is a concern or question on the infection control prevention practices for patients. On the day of survey, the apprentice IPP was not able to receive the notifications for infection prevention consults. This was identified as a potential flaw in the new electronic system but not fixed at the time of survey . Based on interview with the regional system infection control director, the facility's information technology department was notified and it was unknown when the fix would be implemented.

On 12/13/14, Patient #1 underwent several vascular surgeries. In March of 2015, physician #2 diagnosed the patient as having acquired methicillin resistant staphylococcus aureus (MRSA). The patient was admitted to the facility five additional times for inpatient treatment. The facility failed to "flag" the patient as a MRSA patient and implement the subsequent isolation precautions as per the facility's policy on Drug Resistant Infection Prevention.

Patient #3 was a current patient in the facility at the time of survey. The patient was a documented MRSA patient in the historical medical record and was not flagged as a MRSA patient in the current medical record per the facility's policy on alerting the healthcare team. The facility recently transitioned to a different electronic medical record with the possibility the transfer of data did not take place.

Based on interview with the manager responsible for nursing supervisors, the process to place patient's in isolation requires notification to the infection prevention professional. On interview with the apprentice IPP, the information about which patient is currently in isolation is provided on a daily census sheet provided by the nursing supervisor.

The Infection Control P&P states that caregivers will consult the IPP when there is a concern or question on the infection control prevention practices for patients. On the day of survey, the apprentice IPP was not able to receive the notifications for infection prevention consults. This was identified as a potential flaw in the new electronic system.

Based on interview with the Infection Prevention Committee Physician Chairperson, the committee has not met since the departure of the past IPP in 2014. On committee minutes review, the Infection Control Committee met in February 2104 and July 2015 but without physician leadership chairmanship. To reflect the importance of infection control the regulations specifically require that the hospital's QAPI and training programs must be involved in addressing problems identified by the infection control program, and hold the CEO, medical staff and DON jointly responsible for linking the infection control program with the QAPI and training programs. These requirements were not found at time of survey.

See tags 0748 and 0749.

Based on interview, document review and observation, the hospital failed to have a qualified Infection Prevention Professional at the time of survey. Failure to have a designated hospital assigned IPP places patients at risk of acquiring infections.

Findings include:
PeaceHealth St. John has had a void in the coverage of an assigned infection prevention professional (IPP) to oversee the facility's program. The organization hired an apprentice IPP but at the time of survey this individual did not hold the required credentials as defined by Center of Disease Control (CDC). CDC has defined " infection control professional " as " a person whose primary training is in either nursing, medical technology, microbiology, or epidemiology and who has acquired specialized training in infection control. " At the time of survey, the apprentice did not possess the above credentials.

The hospital did not have a policy designating in writing an individual as its infection control officer. The hospital designated a member of the medical staff to chair the Infection Control Committee but no specific person was designated as the Infection Control Officer.

The above information was validated by the Quality Director and apprentice IPP.

Based on interview, document review and observation, the hospital failed to have an ongoing infection control program. Failure to have an active infection control program at all times places patients at risk of hospital acquired infections.

Findings include:
The hospital is expected to identify and track infections and communicable diseases. At the time of survey, based on interview with the nurse manager of nursing supervisors, the process to place patient's in isolation requires notification to the infection prevention professional. On interview with the apprentice IPP, the information about which patient is currently in isolation is provided on a daily census sheet provided by the nursing supervisor and does not have initial involvement with the IPP.

The Infection Control Policy and Procedure (P&P) states that caregivers will consult the IPP when there is a concern or question on the infection control prevention practices for patients. On the day of survey, the apprentice IPP was not able to receive the notifications for infection prevention consults. This was identified as a potential flaw in the new electronic system but not fixed at the time of survey.

On 12/13/14, Patient #1 underwent several vascular surgeries. In March of 2015, physician #2 diagnosed the patient as having acquired methicillin resistant staphylococcus aurous (MRSA). The patient was admitted to the facility five additional times for inpatient treatment. The facility failed to "flag" the patient as a MRSA patient during the August 2015 admission and implement the subsequent isolation precautions as per the facility's policy on Drug Resistant Infection Prevention. Based on interview with the IPP and system infection control director, the "flag" is only implemented when the MRSA is confirmed by a positive laboratory test. The IPP and system infection control director confirmed that not flagging MRSA with a physician diagnoses only was a gap in their system.

Patient #3 was a current patient in the facility at the time of survey. The patient was a documented MRSA patient in the historical medical record and was not flagged as a MRSA patient in the current medical record per the facility's policy on alerting the healthcare team. The facility transitioned to a different electronic medical record in July and August of 2015 with the possibility the transfer of data did not take place.

Based on interview with the nurse manager of nursing supervisors, the process to place patient's in isolation requires notification to the infection prevention professional. On interview with the apprentice IPP, the information about which patient is currently in isolation is provided on a daily census sheet provided by the nursing supervisor.

The Infection Control P&P states that caregivers will consult the IPP when there is a concern or question on the infection control prevention practices for patients. On the day of survey, the apprentice IPP was not able to receive the notifications for infection prevention consults. This was identified as a potential flaw in the new electronic system.

Based on interview with the Infection Prevention Committee Physician Chairperson, the committee has not met since the departure of the past IPP in 2014. Based on interview with the IPP, the committee met February 2104 and July 2015 but without physician leadership chairmanship. The Infection Committee Charter states the committee is to meet monthly and be chaired by a physician chairperson. To reflect the importance of infection control the regulations specifically require that the hospital's QAPI and training programs must be involved in addressing problems identified by the infection control program, and hold the CEO, medical staff and DON jointly responsible for linking the infection control program with the QAPI and training programs. These requirements were not found at time of survey.

The above information was validated by the Quality Director and apprentice IPP.