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.

SUMNER COMMUNITY HOSPITAL 1323 NORTH A STREET WELLINGTON, KS 67152 Feb. 12, 2015
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and staff interview the hospital failed to follow their policy and procedure to ensure patients receive care in a safe setting for one of two patients sampled(patient #10) with suicidal precautions.

Findings include:

- The hospital's policy titled, "Suicide Precautions" reviewed on 2/11/15 at 1:00 pm directed, "...Documentation of observations of the patient by the nursing staff shall be made every ten (10) minutes...Patient should remain in direct line of view of staff at all times while awake...Patient may attend unit activities under constant supervision.

- Patient #10's record review on 2/11/15 revealed he/she presented to the BHU at Sumner County Regional Medical Center on 2/6/15 from a skilled nursing facility with reason for admit documented as suicidal ideation and depression, and medical diagnoses of [DIAGNOSES REDACTED] pm and 6:00 pm and on 2/9/15 between 3:00 pm and 3:20 pm. Staff failed to follow physician orders to conduct suicide observations every 10 minutes as ordered. This failure placed patient #10 at risk to harm themselves for lack of 10 minute observations as ordered.

- Patient #10 observed on 2/9/15 and 2/10/15 revealed the patient wandering in the halls, in the day room and into the conference room.

Staff A, nurse manager, interviewed on 2/11/15 reviewed patient #10's "Individual Observation Record" and confirmed staff failed to conduct suicide observations every 10 minutes as ordered.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review, document review and staff interview, the hospital's behavioral unit (BHU) failed to ensure nursing staff followed the policies to supervise, evaluate and document treatments, nursing cares, interventions and prevention for one of 11 sampled patients (patient #1) identified with pressure ulcers. The hospital failed to ensure nursing staff followed their policy's for documentation of suicidal observations for two of 11 patients identified on suicidal precautions (Patient #'s 10 and 11). This deficient practice placed all patients admitted to the unit at risk for potential harm.

Findings include:

- Policy titled "Pressure Ulcer Prevention dated 11/11/14" directed nursing staff to use the "Guidelines for staging Pressure Ulcers and Stasis Wounds. Guidelines are noted in this policy. The Pressure Ulcer Staging Guidelines described a Stage II as partial thickness loss of dermis, presents as shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or ruptured blister with either serous or serosanguinous fluid. Presents as a shiny or dry shallow ulcer without slough or bruising. Pressure ulcers and stasis wounds should be assessed weekly, utilizing the EZ Graph Tool and scanned into the electronic medical record. If the patient's Braden Scale score places them in a "high" or "severe" risk, they should be repositioned at least every 2 hours or more often.

Policy titled "Wound Skin Protocol" dated 8/2010 directs nursing to assess skin integrity for open wound or skin abrasion, the Braden Score will be documented by the RN upon admission and updated weekly. Photographs of all wounds will be taken and measured to show wound sizes, nursing is to notify the wound care nurse, wound care nurse is to begin wound protocol,nursing is to reduce or relieve by repositioning and providing pressure reducing surface, e.g. air mattress, patients repositioned every two hours, if wounds are staged, if eschar/sloughing are present, document the depth and extent of the wound on EZ graph tool by wound care nurse. The policy requires; 1) a complete description of the wound, size, depth, length, width, color, and drainage. 2) Status of the wound bed, presence of eschar, tunneling, sinus tracts, exposure of fascia, tendon, or bone. 3) Condition of the skin around the wound. 4) All aspects of wound care, date and time performed as well as type of treatment or dressing applied. 5) Subjective symptoms of [DIAGNOSES REDACTED].

- Patient #1's medical record reviewed on 2/10/15 revealed an admission date of [DATE] with a diagnosis of [DIAGNOSES REDACTED]#1's behaviors became irritable and resistive to cares and noted the patient had a large bleb (a fluid area under the skin) on the back of the left heel, an open blister on the right upper back and left buttock and redness to the buttocks. Nursing applied calmoseptine ointment (multipurpose moisture barrier temporarily relieves discomfort & itching). RN staff J noted at 11:00 am on 1/3/15 patient #1 behaviors osculated to combative and irritable which continued until 12:35 am on 1/4/14. Staff J documented during the times of combative/irritable behaviors the patient dragged their left foot on the bed creating the fluid filled blister on left heel to open and weep despite pillows place below the bilateral legs. The medical record lacked evidence nursing followed the policy for Pressure Ulcer Prevention that identified the unopened/opened blisters as stage II pressure ulcers and implemented the EZ graft tool (a tool used to describe, measure and monitor the progression of non-healing/healing pressure ulcers). The medical record showed the patient's admission Braden Scale (assesses a patient's risk of developing a pressure ulcer by examining six criteria) score at 16 points out of 18 points which placed patient #1 at risk for skin breakdown. The medical record lacked evidence the wound care nurse documenting photographs or appearance, color, size and depth of the blisters/wounds and nursing failed to document every two hours the pressure relieving device used and repositioning of the patient.

- Administrative RN staff A interviewed on 2/10/15 at 1:15 pm acknowledged patient #1 developed skin blisters following intravenous fluid (IVF) administration due to lab reports that showed the patient as dehydrated. Staff A verified patient #1's medical record lacked documentation of notification to the wound care nurse, notification to the physician, photographs of the wounds, description (including location, color, size, depth, condition of skin around the wound and drainage) of the wounds, implementation of the EZ Graft tool, wound dressing changes as ordered by physician, the patient's response to wound care, interventions for wounds and prevention to include documentation of pressure relieving and every two hour repositioning. Staff A confirmed they were unaware of all the required documentation the policy directed nursing staff to complete and failed to identify patient #1's un-opened/opened blisters as a stage II pressure ulcer.

Administrative Staff K interviewed on 2/9/15 confirmed the hospital does not have a wound care nurse but the behavior unit notifies the hospital's nurse managers for wound care assessments as needed.

- The hospital's policy titled, "Suicide Precautions" reviewed on 2/11/15 at 1:00pm directed, "...Nursing observation shall be documented on the 24 hour Observation Form and at least one nursing note every four (4) hours shall be written ..."

- Patient #10, presented to the BHU at Sumner County Regional Medical Center on 2/6/15 from a skilled nursing facility with reason for admit documented as suicidal ideation and depression, and medical diagnoses of [DIAGNOSES REDACTED]'s notes) on 2/7/15 at 9:59 am, and 2:49 pm, on 2/8/15 at 4:12 am and 3:15 pm, on 2/9/15 at 4:54 am and 4:25 pm, and on 2/10/15 at 4:40 am and 3:59 pm. Nursing staff failed to follow the hospital ' s Suicide Precautions policy to write at least one nursing note every four hours.

Staff A, nurse manager, interviewed on 2/11/15 reviewed patient #10's medical record and confirmed nursing staff failed to write at least one nursing note every four hours on patient #1.

- Patient #11 medical record reviewed on 2/11/15 revealed an admission date of [DATE] with a diagnosis of [DIAGNOSES REDACTED][DIAGNOSES REDACTED], seasonal allergies, urinary retention and epilepsy. Record review revealed the patient was placed on suicide precautions on 1/9/15 at 5:19 pm and the physician discontinued the suicide precautions on 1/14/15 at 11:10 am. The medical record lacked documentation the licensed nurse wrote a progress note every four hours as required by the hospital's policy.

- Administrative staff A interviewed on 2/11/15 at 3:15 pm acknowledged the medical record lacked nursing progress notes documented every four hours as required by policy. Staff A verified they were unaware of the suicide precaution policy that required the nurse to document every four hours.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review, document review and staff interview, the hospital failed to ensure nursing staff developed and keeps current a nursing care plan for each patient as part of the interdisciplinary care plan for one of 11 patient ' s sampled (Patient #1). The failure to ensure nursing services developed and updated the care plan for patients at risk for impaired skin integrity or who developed skin breakdown at risk for harm.

Findings include:

- Policy titled "Care Plans", dated 5/28/13, reviewed on 2/10/15 directed staff to update the patients care plan on a daily basis.

Policy titled "Wound and Skin Protocol, Policy 2.47, dated 8/18" reviewed on 2/9/15 directed staff to completed skin assessments to identify the staging of wounds and treatment options. The policy directed skin assessments to be completed at admission and re-assessed during each nursing shift. The policy directed nursing staff to address all patients at risk for altered skin integrity in the nursing care plan.

- Patient #1's medical record reviewed on 2/10/15 revealed an admission date of [DATE] with a diagnosis of [DIAGNOSES REDACTED]'s admission Braden Scale (assesses a patient's risk of developing a pressure ulcer by examining six criteria) score at 16 points out of 18 points which placed patient #1 at risk for skin breakdown. Nursing developed plans of care for fall risk, impaired physical mobility, ineffective coping, and anxiety. On 1/3/15 at 6:40 pm registered nurse (RN) staff A noted the patient had a large bleb( a fluid filled area under the skin) on the back of the left heel and an opened blister on the right upper back and left buttock. Nursing staff A noted the patient had redness to the buttocks. Nursing staff J documented at 12:35 am on 1/4/15 the patient dragged their left foot the bed creating a fluid filled blister on left heel to open and weep despite pillows place below the patient ' s legs. Nursing applied an ABD pad to the left heel and secured the pad with kerlix. The medical record lacked a plan of care for the potential for impaired skin integrity at admission and lacked an update to the original plan of care dated 1/3/15 to 1/7/15 to include the left heel blister/opened, open blisters on the upper back and left buttock.

RN staff A interviewed on 2/10/15 at 10:15 am acknowledged they took care of patient #1 on 1/3/15. Staff A stated the physician ordered an intravenous (IV) of normal saline when patient #1 lab report came back with a critical value for the BUN indicating the patient was grossly dehydrated. Staff A shared that after the second day and into the third day of the IV therapy the patient's skin began itching and noted during an assessment the abdomen appeared to show fluid under the skin (third spacing). The physician ordered a CT scan of abdomen to rule out fluid overload. Staff A verified on 1/3/15 the patients upper back, left buttock and left heel had blisters. Staff A confirmed they assisted patient #1 being transferred from the toilet into a wheel chair when patient #1 rubbed/slid against the back of the wheelchair and opened the upper back and left buttock blister. Staff A confirmed nursing staff failed to update patient #' s nursing plan of care to include a plan of care for risk/actual impaired skin integrity for the unopened/opened blisters.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation and staff interview the hospital failed to ensure they maintained the physical environment of the behavior health unit (BHU) in a manner for the safety and well-being for patients assessed at risk for suicide 1 of 1 sampled patients (patient # 10) and one of one closed records reviewed (patient #11). This deficient practice placed all patients assessed at risk for suicide at risk for potential self harm.


Findings include:


- Patient #10's record review on 2/11/15 revealed he/she presented to the BHU at Sumner County Regional Medical Center on 2/6/15 from a skilled nursing facility with reason for admit documented as suicidal ideation and depression, and medical diagnoses of [DIAGNOSES REDACTED] between 5:30 pm and 6:00 pm and on 2/9/15 between 3:00 pm and 3:20 pm.

- Patient #10 observed on 2/9/15 and 2/10/15 revealed the patient walking in the halls, in the day room and into the conference room.


- Patient #11's closed record review on 2/11/15 revealed he/she presented to the BHU at Sumner County Regional Medical Center on 1/9/15 and was discharged on [DATE] with reason for admit documented as schizoaffective disorder, depressed type, hallucinations and suicidal ideation that included a suicide attempt by reportedly going out in front of the home in moving traffic with medical diagnoses of [DIAGNOSES REDACTED][DIAGNOSES REDACTED], seasonal allergies, urinary retention and epilepsy. Review of the physician orders directed suicide observations every 10 minutes. Medical Record review revealed patient remained on suicide precautions from admission through 1/14/15 at 11:10am.


- Observation of the BHU's five patient rooms and one dayroom on 2/11/15 between 11:15 am and 12:00 pm revealed the following;

Observation of each patient room revealed;

1) an entry way with a suspended ceiling with 12 tiles, 12inch by 12 inch each.
2) an entry way sink with one faucet with two handles, four inches wide and two inches tall with exposed pipes 13 inches from the floor.
3) Wall mounted light over sink measured 25 inches long and 8 inches from the wall 4) patient room door handles were three inches wide and 1.5 inches from the door
5) entry way cabinet had four doors with C-handles 4.5 inches wide and one inch from the door
6) each patient room had two metal closet with C-handles 4.5 inches and 1.5 inches from the door
7) patient room had four uncovered electrical outlets
8) each room had two beds with two rails on each bed, an electrical cord and room 223 had one bed with four rails
9) each room had two wall mounted florescent light fixtures with a plastic insert covering
10) One mini blind with cord greater than 12 inches
11) Each room had one thermostat 3 inches long and 1.5 inches from wall
12) One light switch with non-tamper proof screws
13) One window with two handles, four inches long and one inch from the window

Observation of the bathroom in each patient room revealed;

1) a toilet with hinged seat and exposed pipes 24 inches from the floor and 4.5 inches from the wall
2) one sink with one faucet 12 inches tall with two handles four inches wide and two inches tall. Metal pipes under sink were exposed 13 inches from the floor.
3) Wall mounted light over sink measured 25 inches long and 8 inches from the wall
4) Bathroom door had two round knobs three inches from the door.
5) Metal grab bar attached to the wall by the toilet was 27 inches long and 4.5 inches from the wall.
6) Shower had a temperature knob one half inch from the wall, round shower head three inches from the wall and two grab bars (one 27 inches long, one 26 inches long and both 4.5 inches from the wall.
7) A metal shelf unit with five shelves each shelf 12inches wide with a half inch gap on each side of the shelf.

Observation of the Dayhall room revealed;

1) One IV pump with a cord greater than 12 inches long.
2) Two windows with four handles, four inches long and one inch from the window.
3) One framed cork board mounted to the wall with two non-tamper proof screws
4) One picture board mounted to the wall with two non-taper proof screws
5) Pre-fabricated cabinets, with six doors and two drawers, with C-handles four inches long and one inch from the surface.
6) A sink with a 20 inch tall faucet and two 13 inch long handles
7) A thermometer unit (for obtaining patient temperatures) with a cord greater than 12 inches.
8) A computer adapter cord greater than 12 inches long (approximately three feet long).

Observation of the dayhall room bathroom revealed;

9) an entry way with a suspended ceiling with 12 tiles, 12inch by 12 inch each.
10) an entry way sink with one faucet with two handles, four inches wide and two inches tall with exposed pipes 13 inches from the floor.
11) Wall mounted light over sink measured 25 inches long and 8 inches from the wall
12) a toilet with hinged seat and exposed pipes 24 inches from the floor and 4.5 inches from the wall
13) one sink with one faucet 12 inches tall with two handles four inches wide and two inches tall. Metal pipes under sink were exposed 13 inches from the floor. 14) Wall mounted light over sink measured 25 inches long and 8 inches from the wall
15) Bathroom door had two round knobs three inches from the door.
16) Metal grab bar attached to the wall by the toilet was 27 inches long and 4.5 inches from the wall.
17) Shower had a temperature knob one half inch from the wall, round shower head three inches from the wall and two grab bars (one 27 inches long, one 26 inches long and both 4.5 inches from the wall.

Observation of the BHU's hallway and items observed on the unit revealed;

1) A dropped ceiling with 12 by 12 inch tiles
2) Seven fluorescent lights in hallway with a plastic insert covering, easily removed.
3) Six electrical outlets easily accessible.
4) Fire door at north end of hall had a bar handle 43 inches long five inches for the door.
5) Three mobile (with wheels) soiled linen carts with blue plastic bag liners plus extra plastic bags hanging on the back of the cart.
6) Patient gowns with ties to secure the gowns, and fitted sheets with elastic on the short ends of the sheets.



The professional standards were identified as coming for these sources:

The Veteran's Health Administration (VHA) National Center for Patient Safety formed a national committee that developed The Environment of Care Checklist for the purpose of reducing environmental factors that contribute to inpatient suicides, suicide attempts, and other self-injurious behaviors. This initiative is consistent with current literature on prevention of suicidal behaviors (Suicide Prevention Strategies: A systematic review. The Journal of the American Medical Association, (JAMA), 2005, v 294, 2064-2074).

JAMA, published continuously since 1883, is an international peer-reviewed general medical journal published 48 times per year. JAMA is the most widely circulated medical journal in the world.

The VHA and JAMA have all established accepted standards of practice for psychiatric inpatient facilities in the United States.

The VHA committee developed the Mental Health Environment of Care Checklist (MHEOCC) with the goal to prospectively identify and eliminate environmental risks for inpatient suicide and suicide attempts. The following are some of the items included on the MHEOCC to reduce environmental risks for inpatient suicide:

- Faucets and spouts in sinks and showers should be an institutional type. There should be no handheld shower devices and no temperature adjusting devices within the showers (unless recessed). Institutional faucets will not provide an anchor point for hanging exposed plumbing pipes created a looping hazard.

-Furniture should be free of anchor points.
-Closet doors should be free of anchor points.
-Door handles should be free of anchor points.
-Pictures and wall hanging should be tamper resistant screws or anchors.
-Vents should be secured to the wall or ceiling with tamper resistant screws or anchors.
-Ceilings should be constructed of solid materials.
-Electrical outlets should be protected and tamper resistant.
-Light fixtures should be flush mounted and tamper resistant.
-Hospital gowns should have no strings and fitted sheets should not have elastic.


Administrative nursing staff K interviewed in the conference room on 2/11/15 at 11:15 am acknowledged the unit was remodeled and opened in 1998. Staff K verified they were unaware of the new standards for ligature risk on a behavioral unit.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
The hospital reported a census of nine patients with a licensed bed capacity of ten. Based on observation, policy review, and staff interview the hospital's infection control officer failed to develop and maintain an active infection control system ensuring hospital personnel followed basic infection control practices for two of two observed glucometer (blood sugar analyzer) tests (patient #9), one of four vinyl recliners in the day room with an approximately eight to ten inch torn right upper corner, two of two vinyl chairs with multiple one to two inch tears located on the seat, five of five cloth chairs with stains, one of one mattress found on dayroom floor, one of one mat with multiple six to eight inch tears, and six of six observations of failure to preform hand hygiene. The infection control officer failed to maintain a surveillance, data collection, and reporting system to track infection control issues. This deficient practice places patients at risk for hospital-acquired infections.

Findings include:

The hospital's infection control policy "Glove use" reviewed on 2/10/15 at 1:00 pm directed nursing staff to "...wash hands or use rub prior to donning gloves ...perform hand hygiene after removing gloves."

The hospital's "hand hygiene" policy reviewed on 2/10/15 at 1:05 pm directed staff to "...decontaminate hands after contact with a patient ' s intact skin (e.g. when taking a pulse or blood pressure or lifting a patient)."

The hospital's infection control policy "Equipment, Cleaning and Storage of Patient Care Equipment " reviewed on 2/10/15 at 1:00 pm directed staff "... when equipment is shared, disinfectant of equipment should take place prior to next patient use."

The hospital's policy "infection control program" reviewed on 2/10/15 at 1:10 pm directed the infection control officer " ... to develop and maintain a formal plan for infection control including assessment of risk, services provided, the population served, strategies to decrease risk, and surveillance plan."

- Observation in the day room on 2/9/15 at 11:20 am revealed four mauve colored arm chairs placed around a table with cloth seats and backs. The seats of the chairs had dark stains on them and the wooden arms of the chairs showed the varnish worn off.

Staff F, registered nurse (RN) program director, and staff I, RN, corporate director of Behavioral Health Units (BHU) interviewed on 2/11/15 at 11:30 am acknowledged the mauve colored chairs with the cloth seats did not render them a cleanable surface. Staff I explained the hospital switched the chairs they had in the day room to the cloth chairs because the vinyl chairs they had were " falling apart."

- Nursing staff B, RN, observed on 2/9/15 at 11:35 am performed a finger stick glucometer test on patient #9 in the day room at the table were patient #9 was seated. Staff B wearing gloves on both hands set the glucometer on the table, cleaned a finger of patient #9 ' s with an alcohol swab, fanned the finger dry, performed a finger stick glucometer test, placed the glucometer in a case, returned the glucometer to the locked medicine cart, documented the results of the test in the computer, and removed their gloves. Staff B failed to perform hand hygiene before and after applying the gloves, and failed to clean the glucometer before returning it to the locked medicine cart located in the day room.

- Nursing staff B, RN, observed on 2/9/15 at 11:45 am applied clean gloves to help patient #8 up from the blue mat they were lying on. Unable to get patient #8 up, staff B went to the patient's bathroom wearing the same gloves, to get help from staff E where they were, in the bathroom with another patient. Staff E removed their gloves and applied clean gloves to help patient #8 off of the mat with the help of a blue gait belt and sat patient #8 in a recliner, staff E put the gait belt on a counter in the day room. Staff B helped the patient out of the bathroom. Staff B and E failed to perform hand hygiene before applying clean gloves and staff B failed to remove their gloves when having contact with one patient to another. Staff E failed to clean the gait belt as directed in the hospital's policy "Equipment, Cleaning and storage of Patient Care Equipment."

- Nursing staff B, RN, observed on 2/9/15 at 2:00 pm performing a dressing change on patient #8's skin tears on the left forearm. Staff B wearing clean gloves removed the dressing, removed the unclean gloves, applied clean gloves, cleaned the skin tear with sterile water, applied a non-stick dressing and wrapped the arm. Staff B applied gloves, removed band aide from a small skin tear on patient # 8's left forearm. Staff B using steri-strips applied some to the skin tear, dropped the package of steri-strips on the floor, picked them up and continued to apply the steri-strips that had dropped on the floor to the skin tear. Staff B failed to perform hand hygiene after removing gloves, when applying gloves, and used the contaminated steri-strips on the patient.

- Nursing staff D, Licensed Practical Nurse (LPN), observed on 2/10/15 at 11:30 am, performed a finger stick glucometer test on patient #9 in patient # 9's room wearing gloves on both hands. Staff D applied gloves without performing hand hygiene and performed a finger stick glucometer test on patient #9, staff D then removed the gloves from their hands, performed hand hygiene, and returned glucometer to the locked medicine cart. Staff D failed to perform hand hygiene, and failed to clean the glucometer before returning it to the locked medicine cart located in the day room.

-The BHU's laundry room observed on 2/10/15 at 11:05 am revealed non-disinfectant type laundry soap used to wash patient ' s laundry. Instructions posted in the laundry direct staff "After washing each load of patient clothing ...Place one cup of bleach in the washer ... Run the washer on shot cycle ... use hot water."

-Review of the "bleach cycle" log on 2/10/15 at 11:05 am revealed staff failed to perform a bleach cycle on dates 12/27/14-1/5/15, 1/8/15-1/19/15, and 1/21/15- 2/1/15 as directed in the posted instructions.

-Nursing staff D interviewed on 2/10/15 at 11:10 am acknowledged staff failure to perform bleach cycles after washing each load of patient clothing.

-Nursing staff D interviewed on 2/10/15 at 11:10 am revealed no knowledge of wash cycle or temperature.

- The hospital's dayroom observed on 2/9/15 at 11:05 am revealed two CNA's and one RN assisting patient #8 to a torn blue mat located on the floor. All three staff members stood on the mat while assisting the patient thus exposing patient #8 to contaminants from the bottom of their shoes. The tears on the blue mat rendered the surface uncleanable.

- Nursing staff H observed on 2/9/15 at 11:00 am assisted a patient from a wheelchair to reclining chair using a gait belt. Staff H placed the used gait belt around their waist prior to putting it away. Staff H failed to clean the equipment as directed in the hospitals policy "Equipment, Cleaning and Storage of Patient Care Equipment."

Infection Control Nurse Staff G interviewed on 2/10/15 at 1:30 pm revealed the hospital units survey themselves by filling out surveillance sheets and turning them into staff G. Staff G collects the data from the sheet and notifies housekeeping or building maintenance of any issues requiring their services. Staff G notifies the safety committee and every three months sends a report to medical staff. Staff G revealed there is no formal written document and information sent to Quality Assessment and Performance Improvement (QAPI) committee.

Infection Control Nurse Staff G interviewed on 2/10/15 at 2:30 pm revealed no information from the surveillance conducted by staff G, one time yearly on each unit, is sent to the Quality Health Care or taken to Quality Health Care meetings. Staff G revealed no Quality Health Care measures are in place at this time for infection control surveillance.

Infection Control Nurse Staff G interviewed on 2/10/15 at 3:00 pm revealed the facility has no laundry policy.

Infection Control Nurse Staff G interviewed on 2/10/15 at 2:45 pm revealed the hospital does not currently have an infection control nurse. Staff G revealed if nursing staff calls and requests someone to look at a wound a nurse from either the critical care areas or staff G will come over and look.