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.

A person or persons must be designated as infection control officer or officers to develop and implement policies governing control of infections and communicable diseases.

Based on interview, it was determined that the hospital failed to designate an infection control officer. Failure to do placed the hospital at risk for an incomplete, inaccurate and/or unimplemented infection control program.

Findings include:

On 4/20/2011, the person identified by the hospital as the Infection Control Coordinator (ICC) was interviewed. S/he reviewed the position description for the ICC and stated the position description was not accurate because it stated that the ICC "participates in appropriate professional organizations including American Association of Occupational Health Nurses (AAOHN)). The ICC stated that s/he did not belong to the organization because s/he was not a nurse, and also stated that s/he did not belong to any other professional organizations due to cost.

The ICC also stated that there was not an Infection Control Officer designated in the hospital, but that the hospital utilized the expertise of the physician who was the Director of the local health department, as well as the hospital's chief of medical staff.

The ICC stated that the role of the physician who was the Director of the local health department was to provide consultation for infectious diseases, as well as to provide consultation regarding infection control practices in the hospital.

On 4/21/2011, the hospital Administrator stated that the ICC and the Chief of Staff worked closely with the Director of the Clallam County Health Department, and that the Director attended infection control meetings, reviewed and advised on policies and procedures and was working with the hospital regarding quality and safety issues. The Administrator confirmed that the hospital did not have a position description for the Director to define the Director's role in the hospital, including responsibilities and lines of communication, nor was there a contract stating what the Director's involvement was with the hospital.

The Chief of Staff was also interviewed on 4/21/2011 and stated that the Director of the Clallam County Health Department was involved in provided consultation regarding infection control and public health issues and was "very present". S/he also stated that the ICC came to her/him and the Director with any issues s/he identified.