The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on interviews and record reviews the hospital failed to ensure that acceptable infection control protocols, on the identification, reporting, investigating and controlling of infections and communicable disease of patients and personnel, were adhered to as evidenced by the infection control surveillance program failing to place 1 of 1 patient (Patient #5) suspected of a surgical site wound infection on isolation precautions prior to lab report results being reported.

A review of the the hospital's Isolation Guidelines- General Procedures, as provided by S4RN/ICN as the most current, revealed in part: Patients with draining wounds will be isolated until such times as cultures make it clear that pathogenic bacteria are not present. When such patients are not isolated by order of their physician, the charge nurse will notify the infection control nurse who will report this to the Chairman of the Infectious Control Committee.

A review of Patient #5's medical record revealed in part: patient was a [AGE] year old female, status post exploratory laporatomy surgical procedure admitted on [DATE] under the care of S5Medical Director for wound care for an abdominal wound dehiscence. A review of the nurse's, "Wound Documentation" sheet dated 7/10/15 revealed in part: Abdominal wound care as ordered, serosanguineous purulent drainage with peripheral tissue edema noted. A review of the Physician Order sheet revealed an order dated 7/10/15, co-signed by S5Medical Director, for a wound C&S (culture and sensitivity) of the abdominal wound. There was no documented evidence of a Physician Order for any isolation precautions. The culture was taken and sent to the lab on 7/10/15.

In an interview on 7/17/15 at 2:10 p.m. with S10RN (Registered Nurse), she indicated that she was probably the charge nurse on 7/10/15 when Patient #5's cultures were obtained and sent to the lab. S10RN was asked if Patient #5 had been placed on any isolation precautions until her lab culture results were reported. S10RN indicated that S5Medical Director did not order any isolation precautions for Patient #5. S10RN further indicated that she did not think that nurses could place patients on isolation precautions without a physician order. S10RN indicated that she had been employed for a few months and had received infection control in-services upon hire.

In an interview on 7/17/15 at 2:15 p.m. with S4RN/ICN (Infection Control Nurse) she indicated that she was the designated Infection Control Officer for the hospital. S4RN/ICN was asked if nurses could place patients on isolation precautions without a physician order. S4RN/ICN indicated that nurses could initiate isolation precautions without a physician order. S4RN/ICN was asked about Patient #5's C&S.. S4RN/ICN indicated that she was not aware the Patient #5 had had a C&S ordered. S4RN/ICN indicated that she performed chart audits randomly and had not performed any chart audits in over a week. S4RN/ICN was asked if nurses were supposed to contact the Infection Control Nurse when C&S were ordered by physicians and before the lab results were obtained from the lab. S4RN/ICN indicated that staff are required to notify the Infection Control Nurse of any C&S cultures. S4RN/ICN further indicated that all staff are in-serviced on infection control protocols upon hire and annually. S4RN/ICN indicated that she did not think that patients had to be on any isolation precautions if the drainage was minimal and covered, even if they suspected a wound infection. S4RN/ICN indicated that she had been the Infection Control at the hospital for about one year and attended several infection control in-services/programs.