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.

CROOK COUNTY HOSPITAL 713 OAK STREET SUNDANCE, WY 82729 Nov. 13, 2013
VIOLATION: COMPLIANCE WITH STATE AND LOCAL LAWS Tag No: C0152
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of infection control activities, the facility failed to comply with State requirements for reporting diseases and epidemiologically significant conditions for 2 (#1 and #2) of 5 sample patients with reportable conditions. The findings were:

1. Review of infection control records on 11/13/13 beginning at 8:40 AM showed 5 patients were identified in 2013 with infections or conditions that required reporting to the Wyoming Department of Health as specified in Statue Statute Title 35 - Public Health and Safety, Section 35-4-107. The statue requires reporting of significant infections and conditions to the health department within 24 hours of discovery; among the conditions defined for reporting by the Health Department are [DIAGNOSES REDACTED] and campylobacteriosis. Of the 5 sample patients with reportable conditions, the facility failed to comply with timely reporting for 2 patients, for example:
A. Patient #1 had a diagnosis of [DIAGNOSES REDACTED].
B. Patient #2 had a diagnosis of [DIAGNOSES REDACTED]

2. The infection preventionist confirmed in interview on 11/13/13 beginning at 9:10 AM that the facility failed to comply with timely reporting as required by the State in the 2 instances cited.
VIOLATION: POLICIES - INFECTION CONTROL Tag No: C0278
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of infection control activities, the facility failed to implement an effective system for identifying and reporting diseases and epidemiologically significant conditions to the Wyoming Department of Health. The deficiency was evident in late reporting for 2 of 5 State-mandated reportable conditions (patients #1 and #2), failure to submit 1 of 1 bacterial isolates for confirmatory testing (patient #2), and failure to provide timely follow-up information requested by the health department. In addition, 4 of 5 patients (#2, #3, #4, #5) had incomplete reporting records. The facility further failed to ensure the infection preventionist (IP) had sufficient education and training to direct the infection control program. The findings were:

1. On 11/13/13 beginning at 8:05 AM infection control activities were reviewed with the hospital infection preventionist (IP). Evidence gathered from document review and interview revealed the following deficiencies in the infection control program:
A. A sample of patients with reportable diseases and conditions occurring in 2013 were reviewed. Of 5 individuals with infections or conditions that require reporting to the Wyoming Department of Health within 24 hours, 2 (patients #1 and #2) were reported late. Patient #1 had a diagnosis of [DIAGNOSES REDACTED]#2 had a diagnosis of [DIAGNOSES REDACTED]. Subsequent interview with the laboratory manager on 11/13/13 at 2:20 PM further confirmed the dates of diagnostic findings and reporting to the State; she stated the late reports were an oversight.
B. Of 5 patients with reportable conditions in the survey sample, 4 (patients #2, #3, #4, and #5) had incomplete reporting records. State Statute (Chapter 35, Section 35-4-107) requires specific documentation to accompany disease reports; the 4 incomplete records lacked one or more data elements for patient demographics, contact information (address or telephone number), occupation, record of hospitalization , and dates of reporting. The IP confirmed in interview on 11/13/13 at 10:50 AM the required reporting information was missing from the 4 records cited.
C. One patient (#2) was diagnosed with [DIAGNOSES REDACTED]. The information revealed that the facility failed to submit a bacterial isolate to the Public Health Laboratory for testing. The laboratory manager confirmed in interview on 11/13/13 at 3:45 PM that a bacterial isolate was not submitted to the Public Health Laboratory.
D. On 11/13/13 email correspondence and telephone logs solicited from the Infectious Disease Epidemiology Program, Wyoming Department of Health were reviewed. These documents showed that 9 requests for additional information on patient #2's infection were made to the hospital between 7/25/13 and 8/15/13 (16 days) before the hospital replied with the requested information. Per telephone interview with epidemiologists #1 on 8/22/13, the facility's failure to reply in a timely manner prevented completion of an open investigation for 25 days beyond the point of initial diagnosis. The timeline reported by the epidemiologist was confirmed in interview with the laboratory manager on 11/13/13 at 3:50 PM.
E. Hospital policies and procedures on mandatory reporting were reviewed with the IP on 11/13/13 beginning at 9:15 AM. The current procedure, last reviewed and updated 3/25/09, was discovered to contain outdated references to mandatory reporting requirements. The procedure further failed to identify how mandatory reporting was accomplished and how the process was managed for compliance. There was an absence of direction for follow-up and accountability for prompt and accurate reporting. The IP acknowledged there was no central register or log to track reportable diseases, nor was there an established method of communicating disease reporting to the IP. Without a central log and effective communication, the IP stated she was unaware when reporting was required and if it was completed.

2. Interview with the IP on 11/13/13 beginning at 1:15 PM revealed she had been assigned responsibility for the infection control program 12 months ago. She stated her education and training prior to assuming the roles and responsibilities of the IP did not include include infection control principles beyond that provided in her nursing education. She further stated she had not completed any supplemental training in infection control in the past 12 months. She expressed a desire for training to improve her ability to direct the infection control program.
VIOLATION: PATIENT CARE POLICIES Tag No: C0280
Based on staff interview and review of infection control activities, the facility failed to review and update it policies and procedures for mandatory disease reporting at least annually. The findings were:

The hospital's policy and procedure for reporting diseases and conditions to the Wyoming Department of Health was reviewed on 11/13/13 beginning at 9:10 AM. The procedure was annotated to show it was last reviewed and updated 3/25/09. The policy was discovered to reference outdated reporting requirements (citing 2006 documents) and failed to include sufficient information and direction to direct staff in completing mandatory reporting requirements.

The infection preventionist confirmed in interview on 11/13/13 at 10:30 AM that the policy and procedure reviewed was the most current document and, further, acknowledged there had been no review since 2009.