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Based on the inspection of the Fire Alarm System and the report from the Louisiana State Fire Marshal the hospital failed to meet the Condition of Participation for Physical Environment. (cross reference A0709)

Physicians Alliance Hospital is not in compliance with the requirements of title 42 code of Federal Regulations Part 416.44 (b) (Life Safety Code). The findings that follow in this CMS 2567 demonstrates the non-compliance.

The facility is sprinkled, licensed for 40 with a census of 24 at the time of survey.

Based on interview with the Administrator and Maintenance there were no audible are strobe lights on the first floor when the Fire Alarm is Activated.

On compliant survey on 11/15/2011 at 3:00 PM the Facility was put on Immediate Jeopardy because the Fire Alarm System was yellow tagged on 10/24/11, the System was yellow tagged for the audible and the strobe lights not working on First Floor. Without Audibles and Strobes there is no early detection. This deficient practice could potentially affect 40 Patients in an emergency. The Immediate Jeopardy was taken off at 5:45 PM on 11-15-11 when a Fire Fighter from the Houma Fire Department entered the building and Fire watch was implemented. Fire Watch can be released only by the office of the State Fire Marshal .

Based on the inspection of the Fire Alarm System and the report from the Louisiana State Fire Marshal Physicians Alliance Hospital is not in compliance with the requirements of Title 42 Code of Federal Regulations Part 416.44 (b) (Life Safety Code).
Findings:

Based on visual observation the facility failed to provide a fire alarm system with devices or equipment installed according to NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect 40 of 40 residents.

During the facility tour on 11/15/2011 at 3:00 pm, it was observed that the fire alarm horns/strobes on the first floor did not activate when the fire alarm system was tested. Without audible and visual devices, connected to the fire alarm system, the ones occupying the first floor of the building would not be aware of any possible danger.

The documentation provided by the fire alarm contractor on 10/24/11 indicated that the above devices were not functioning and the system was yellow tagged, indicating that an impairment was present. When interviewed, the administrator and maintenance personnel admitted to knowing that the problem existed

At 3:00 p.m., the facility was placed in Immediate Jeopardy for the fire alarm system horns/strobes not functioning on the first floor.

The Immediate Jeopardy was lifted at 5:45 p.m. when the fireman, who was provided by the Houma Fire Department, arrived to implement the fire watch procedures.
(Cross Reference Findings K0051)

Based on record review and interview, the hospital failed to ensure there was an Infection Control Officer designated and approved to oversee the infection control program by failing to have documented evidenced of a qualified individual appointed as the hospital's Infection Control Nurse. Findings:

Review of the personnel file for S2DON revealed her date of hire as the Director of Nursing (DON) was 10/20/08. Further review revealed there was no documented evidence she was designated in writing as the Infection Control Officer since her date of hire 10/20/08 for approximately three (3) years. There was no documentation of a job description regarding Infection Control Nurse. Further there was no documentation presented that S2DON was qualified through ongoing infection control education, training, or experience to oversee the infection control program for the hospital since 10/20/08 for about 3 years.

In an interview on 11/16/11 at 10:30 a.m., S2DON indicated she was the infection control officer for the hospital since her date of hire on 10/20/08 for about 3 years. The DON indicated there was no documented evidence that she was designated and approved as the infection control officier to oversee the infection control program for the hospital since 10/20/08. She indicated there is no documentation of a job description in her personnel file regarding Infection Control Nurse. S2DON confirmed there was no documentation in her personnel file that she was qualified through ongoing infection control education, training, or
experience to oversee the infection control program since 10/20/08. The DON indicated she had no ongoing infection control education, training, or experience to oversee the infection control program since 10/20/08 for about 3 years.

Based on record review and interview, the infection control officer failed to develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel in the hospital as evidenced by: 1) having inaccurate "Infection Control Worksheets" of all patient cultures collected from April of 2011 through October of 2011; 2) having an inaccurate "Infection Control Log" of patients admitted with organisms/infections from April through October of 2011; 3) having an inaccurate system in place to ensure that the one hundred and thirteen (113) cultures collected from urine, wound, blood, and/or sputum were resulted from April through October of 2011; 4) having no documentation the two hundred and seventy-four (274) cultures collected and reported by the contracted laboratory were tracked and trended from April of 2011 through October of 2011; 5) failing to ensure TB (tuberculin) testing was in compliance with the CDC (Center for Disease Control) guidelines for 2 of 2 physician credentialing files reviewed and 2 of 2 personnel files reviewed as evidenced by no documentation of a TB skin test (S4MD) and no documentation of time administered/time read (S5MD, S1Administrator, S10RN) to ensure compliance with the CDC Guidelines; 6) having nursing staff (S10RN) not following the "Contact Precaution" protocol to don gloves upon entering a patients room for 1 of 12 sampled patients (Patient #10); 7) having nursing staff (S11CNA) not performing handwashing after each patient contact for 2 of 12 sampled patients (Patient #1, #8 ); and 8) having nursing staff (S11CNA) not cleanse the thermometer handle after each patient usage as per protocol for 4 of 12 sampled patients (Patient #1, #8, #9, #10); and 9) failing to identify a HAI (hospital aquired infection) for 1 of 12 sampled patients (#5) as evidenced by positive cultures of the blood and urine. Findings:

1)
Review of the "Infection Control Worksheet" revealed there were missing cultures collected from the patients recorded by the nursing staff on the log from April of 2011 through October of 2011.

In an interview on 11/16/11 at 10:30 a.m., S2DON verified there was missing cultures collected from the patients documented in the nursing logs from April to October of 2011. S2 indicated the infection control log was inaccurate and not kept up-to-date from April of 2011 through October of 2011 as per protocol.

2)
Review of the "Infection Control Logs" revealed there were a total of 152 patients admitted to the hospital from April of 2011 through October of 2011 recorded by the Nurse Liaison. Further review revealed there were twenty-five (25) patients admitted in April of 2011. There was missing data regarding whether or not #R7 had an organism/infection prior to being admitted in April 1, 2011. Further review revealed there were twelve (12) patients admitted to the hospital in May, 2011. There were twenty-one (21) patients admitted into the hospital in June of 2011. There were twenty-three (23) patients admitted into the hospital in July, 2011. Further review revealed there was missing data regarding whether or not R#8 had an organism/infection prior to being admitted in July 14, 2011. There were nineteen (19) patients admitted into the hospital in August of 2011. There were twenty-eight (28) patients admitted into the hospital in September, 2011. There were twenty-four (24) patients admitted into the hospital in October of 2011.

During the same interview on 11/16/11 at 10:30 a.m., S2DON confirmed there were sections that were left blank on the form indicating whether or not the patients were admitted with an organism/infection or were not recorded by the Nurse Liaison for R#7 and R#8 from April of 2011 to October of 2011. The DON indicated the "Infection Control Log" was inaccurate and not kept up-to-date from April of 2011 through October of 2011 as per protocol.

3)
Review of the laboratory culture results from the contracted laboratory service revealed there were a total of one hundred and thirteen cultures collected from urine, wound, blood and/or sputum were resulted from April of 2011 through October of 2011. Further review revealed there were a total of twenty (20) cultures collected from nine (9) urines, five (5) wounds, four (4) blood specimens, and two (2) sputums that read, "Not Done" on the laboratory reports for the month of April. There were a total of twenty-nine (29) cultures collected from five (5) urine samples, nine (9) wounds, and two (2) sputums reports that read, "Not Done" for the month of May. There were a total of eight (8) cultures collected from four (4) urine samples, two (2) wounds, and two (2) sputum specimens that read, "Not Done" on the laboratory reports for the month of June. There were a total of nine (9) cultures collected from six (6) urine samples, one (1) wound, and two (2) sputum specimens that read, "Not Done" for the month of July. There were a total of twelve (12) cultures collected from nine (9) urine samples, two (2) wounds, and one (1) sputum specimen that read, "Not Done" on the laboratory reports for the month of August. There were a total of nineteen (19) cultures collected from twelve (12) urine samples, three (3) blood specimens, and four (4) sputum specimens that read, "Not Done" for the month of September. There were a total of sixteen (16) cultures collected from eleven (11) urine samples, two (2) wounds, one (1) blood specimen, and two (2) sputums that read, "Not Done" on the laboratory reports for the month of October.

In the same interview on 11/16/11 at 10:30 a.m., S2DON verified there were a total of 274 culture results that were not done for the patients from April of 2011 through October of 2011. S2 denied knowledge why the culture results were incomplete from April through October. The DON indicated there is a break in the reporting system for all laboratory cultures collected from April through October of 2011.

4)
Review of the "Infection Control Function Report" and Laboratory Culture Results revealed there was no tracking and trending for the forty-two (42) cultures collected in April of 2011. There was no tracking and trending for the fifty-seven (57) cultures collected in May, 2011. There was no tracking and trending for the thirty-one (31) cultures collected in June of 2011. There was no tracking and trending for the twenty-seven (27) cultures collected in July, 2011. There was no tracking and trending for the twenty-six (26) cultures collected in August of 2011. There was no tracking and trending for the forty five (45) cultures collected in September, 2011. There was no tracking and trending for the forty-six (46) cultures collected in October of 2011.

During the same interview on 11/16/11 at 10:30 a.m., S2DON verified there was no documented evidence of tracking and trending for the forty-two (42) cultures collected in April, for the fifty-seven (57) cultures collected in May, for the thirty-one (31) cultures collected in June, for the twenty-seven (27) cultures collected in July, for the twenty-six (26) cultures collected in August, for the forty five (45) cultures collected in September, and/or for the forty-six (46) cultures collected in October. S2DON indicated there is no system in place to identify whether or not the patients had a community acquired infection and/or hospital acquired infection during their hospitalizations from April of 2011 through October of 2011.

5)
Review of the credentialing file for S4MD revealed no documented evidence of a current TB skin test.

Review of the credentialing file for S5MD revealed a document of a TB skin test administered on 04/05/11 and read on 04/08/11. There is no documentation to indicate the time administered or read to ensure compliance with the CDC Guidelines that the test be read within 48 - 72 hours.

Review of the personnel record for S1Administrator revealed a document of a TB skin test administered on 08/17/11 and read on 08/19/11. There is no documentation to indicate the time administered or read to ensure compliance with the CDC Guidelines that the test be read within 48 - 72 hours.

Review of the personnel record for S10RN revealed a document of a TB skin test administered on 08/01/11 and read on 08/03/11. There is no documentation to indicate the time administered or read to ensure compliance with the CDC Guidelines that the test be read within 48 - 72 hours.

In an interview on 11/16/11 at 10:38 a.m. with S3ADON she confirmed the above findings.

Review of the "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005" published by the CDC (Centers for Disease Control) revealed, in part, "...HCWs (health-care workers) refer to all paid and unpaid persons working in health-care settings who have the potential for exposure to M. tuberculosis through air space shared with persons with infectious TB disease. Part time, temporary, contract, and full-time HCWs should be included in TB screening programs. All HCWs who have duties that involve face-to-face contact with patients with suspected or confirmed TB disease (including transport staff) should be included in a TB screening program. The following are HCWs who should be included in a TB screening program: Administrators or managers...Nurses...Physicians (assistant, attending, fellow, resident, or intern)...".

6)
S10RN:
During an observation conducted on 11/15/11 at 11:25 a.m., Patient #10's door had a sign read, "Contact Precaution". Review of the sign, "Contact Precaution" read, "...(In addition to Standard Precautions) Visitors - Report to Nurses' Station Before Entering Room ...2. Gloves- wear gloves when entering room. Change gloves after contact with infective material. Remove gloves before leaving patient's room ...". Further observation revealed S10RN entered into Patient #10's room without wearing gloves. S10RN left Patient #10's room without performing handwashing. In an interview on 11/15/11 at 11:29 a.m., S10RN indicated she had not donned gloves prior to entering Patient #10's room, degloved, and performed handwashing prior to exiting Patient #10's room as per protocol.

During an interview on 11/15/11 at 2:45 p.m. and at 2:55 p.m., S3ADON indicated she expected all nursing staff (S10RN) to wear gloves prior to entering a patient on "Contact Precautions" as per protocol.

In an interview on 11/15/11 at 3:00 p.m., S2DON indicated that she expected all nursing staff (S10RN) to wear gloves prior to entering a patient on "Contact Precautions" as per protocol.

7)
S11CNA:
An observation on 11/15/11 at 2:10 p.m. was conducted of S11CNA. S11CNA was observed entering Patient #1's room with a dinemap machine. She donned gloves and checked Patient #1's vital signs and temperature. S11CNA removed her gloves. She did not perform handwashing prior to leaving the patient's room with the dinemap machine and walked to Patient #10's room located at the end of the hallway. At 2:15 p.m., S11CNA got a pair of gloves from a box located on the top of a cart that was located outside of Patient #10's room. There was a sign posted on Patient #10's door that read, "Contact Precautions". S11CNA donned gloves and entered Patient #10's room with the dinemap machine. She checked Patient #10's vital signs. At 2:25 p.m., S11CNA donned gloves and put on a gown from the cart located outside of Patient #9's room. Patient #9's door had a sign that read, "Contact Precautions". She checked Patient #9's vital signs. She donned another pair of gloves without performing handwashing. At 2:35 p.m., S11CNA was observed checking Patient #8's vital signs. She did not perform handwashing prior to assessing #8's vital signs.

In an interview on 11/15/11 at 2:35 p.m., S11CNA confirmed she did not cleanse the thermometer handle after using it on Patient #1, #8, #9, and/or #10. S11CNA indicated she did not perform handwashing after she assessed Patient #1's and Patient #9's vital signs as per protocol.

During an interview on 11/15/11 at 2:45 p.m. and at 2:55 p.m., S3ADON indicated she expected all staff (S11CNA) to perform handwashing after direct patient contact as per protocol.

In an interview on 11/15/11 at 3:00 p.m., S2DON indicated that she expected all staff (S11CNA) to perform handwashing after direct patient contact as per protocol.

8)
An observation on 11/15/11 at 2:10 p.m. was conducted of S11CNA. S11CNA was observed entering Patient #1's room with a dinemap machine. She donned gloves and checked Patient #1's temperature. S11CNA cleansed the tip of the thermometer with an alcohol swab. She did not cleanse the thermometer handle with the alcohol swab. At 2:15 p.m., S11CNA checked Patient #10's temperature with the thermometer. S11CNA cleansed the thermometer tip with an alcohol swab. She did not cleanse the handle of the thermometer. At 2:25 p.m., S11CNA checked Patient #9's temperature with the thermometer. She did not cleanse the handle of the thermometer with alcohol after assessing #9's temperature. At 2:35 p.m., S11CNA was observed checking Patient #8's temperature. She did not cleanse the thermometer handle with alcohol after she checked Patient #8's temperature.

In an interview on 11/15/11 at 2:35 p.m., S11CNA confirmed she did not cleanse the thermometer handle after using it on Patient #1, #8, #9, and/or #10 as per protocol.

During an interview on 11/15/11 at 2:45 p.m. and at 2:55 p.m., S3ADON indicated she expected the thermometer to be cleansed from the tip to the handle after each patient usage by S11CNA as per protocol.

In an interview on 11/15/11 at 3:00 p.m., S2DON indicated that she expected S11CNA to cleanse all of the thermometer from the handle to tip after each patient usage as per protocol.

9)

Review of a blood culture report for patient #5 from hospital "a" documented as collected on 08/05/11 and resulted on 08/10/11 revealed " Organism(s) found: NO GROWTH - FINAL REPORT after 5 days".

Review of the Physician's Orders for 10/31/11 at 0825 (8:25 a.m.) revealed a verbal order taken from S4MD that read: "...BC (blood culture) X 1..."

Review of a blood culture report with a "collected date" of 10/31/11 at 0850 (8:50 a.m.) and a "final" report date of 11/02/11 at 0730 (7:30 a.m.) from hospital "c" while patient #5 was in Physicians' Alliance Hospital (blood was sent to hospital "c" as Physicians' Alliance has a laboratory contract with them) revealed the following: "Specimen Description: Blood. Culture Result: Klebsiella Pneumoniae - this organism is an Extended Spectrum Beta Lactamase Producer (ESBL)". The Susceptibility report revealed the Klebsiella Pneumoniae was susceptible (meaning the antibiotic would be effective in treating) to Imipenim (Primaxin) and Tigecycline (Tygacil).

In an interview on 11/15/11 at 2:00 p.m. with S5MD he stated the Klebsiella Pneumoniae was a hospital acquired VAP (ventilator associated pneumonia).

Review of the Physician's Orders dated 11/02/11 at 0809 (8:09 a.m.) revealed S5MD gave the following verbal orders: "Tigacyl 100 mg (milligrams) now X 1 dose and Tygacil 50 mg IV (intravenously) q (every) 12 [hours]". Review of another Physician's Order, taken as a verbal order, on 11/02/11 at 1053 (10:53 a.m.) revealed "Primaxin 500 mg IVPB (intravenous piggy-back) q 12 hours".

Review of a 2nd blood culture report with a "collected date" of 11/06/11 at 0430 (4:30 a.m.) and a "final" report date of 11/13/11 at 0632 (6:32 a.m.) from hospital "c" while patient #5 was in Physicians' Alliance Hospital (blood was sent to hospital "c" as Physicians' Alliance has a laboratory contract with them) revealed the following: "Specimen Description: Blood. Culture Result: Klebsiella Pneumoniae - this organism is an Extended Spectrum Beta Lactamase Producer (ESBL)". The susceptibility report revealed the Klebsiella Pneumoniae was susceptible (meaning the antibiotic would be effective in treating) to Tigecycline (Tygacil) and was now reported as resistant to Imipenim (Primaxin). The patient (#5) had expired on 11/10/11.

Sputum/Urine Cultures

Review of the admission orders for patient #5, dated/timed 09/07/11 at 1300 (1:00 p.m.), revealed S4MD gave orders for a Urine C&S (culture and sensitivity) on admit and a Sputum C&S (on admit for all ventilator patients).

Review of the laboratory report from Hosp "c" revealed the sputum was collected on 09/07/11 at 1705 (5:05 p.m.) and the final report was dated/timed 09/10/11 at 7:03 a.m. Review of the report revealed the culture result was "few Methicillin Resistant Staph Aureus".

Review of the laboratory from Hosp "c" revealed the Urine was collected on 09/08/11 at 0430 (4:30 a.m.) and the final report was dated/timed 09/10/11 at 0709 (7:09 a.m.). Review of the report revealed the culture result was "Candida Albicans."

Review of the Physician's Orders for 10/31/11 at 0825 (8:25 a.m.) revealed a verbal order taken from S4MD that read: "U/A (urinalysis) C&S..."

Review of a laboratory report from hosp "c" revealed the Urine C&S was repeated on 10/31/11. The urine was documented as collected on 10/31/11 at 0859 (8:59 a.m.) and the report was final on 11/02/11 at 0740 (7:40 a.m.). Review of the report revealed the culture result was "Klebsiella Pneumoniae - this organism is an Extended Spectrum Beta Lactamase Producer (ESBL)".

Review of a laboratory report from hosp "c" revealed the sputum C&S was repeated on 10/31/11. The sputum was documented as collected on 10/31/11 at 2030 (8:30 p.m.) and the report was final on 11/03/11 at 0709 (7:09 a.m.). Review of the report revealed the culture result was "few Enterobacter Cloacae Complex and many Methicillin Resistant Staph Aureus".

In an interview on 11/15/11 at 2:00 p.m. with S5MD he stated the Klebsiella Pneumoniae was a hospital acquired VAP (ventilator associated pneumonia).

In an interview on 11/16/11 at 10:30 a.m., S2DON verified there was missing cultures collected from the patients documented in the nursing logs from April to October of 2011. S2 indicated the infection control log was inaccurate and not kept up-to-date from April of 2011 through October of 2011 as per protocol.

Based on record review and interview, the infection control officer failed to maintain an up-to-date log of incidents related to infection as evidenced by:
1) failed to have an up-to-date "Infection Control Worksheet" of all patient cultures collected from April of 2011 through October of 2011, 2) failed to have an accurate "Infection Control Log" of patients admitted with organisms/infections from April through October of 2011,
3) failed to have an accurate system in place to ensure that the one hundred and thirteen (113) cultures collected from urine, wound, blood, and/or sputum were resulted from April through October of 2011, 4) failed to have documented evidence the two hundred and seventy-four (274) cultures collected and reported by the contracted laboratory were tracked and trended from April of 2011 through October of 2011, and 5) failing to ensure TB (tuberculin) testing was in compliance with the CDC (Center for Disease Control) guidelines for 2 of 2 physician credentialing files reviewed and 2 of 2 personnel files reviewed as evidenced by no documentation of a TB skin test (S4MD)and no documentation of time administered/time read (S5MD, S1Administrator, S10RN) to ensure compliance with the CDC Guidelines. Findings:

1)
Review of the "Infection Control Worksheet" revealed there were missing cultures collected from the patients recorded by the nursing staff on the log from April of 2011 through October of 2011.

In an interview on 11/16/11 at 10:30 a.m., S2DON verified there was missing cultures collected from the patients documented in the nursing logs from April to October of 2011. S2 indicated the infection control log was inaccurate and not kept up-to-date from April of 2011 through October of 2011 as per protocol.

2)
Review of the "Infection Control Logs" revealed there were a total of 152 patients admitted to the hospital from April of 2011 through October of 2011 recorded by the Nurse Liaison. Further review revealed there were twenty-five (25) patients admitted in April of 2011. There was missing data regarding whether or not R#7 had an organism/infection prior to being admitted in April 1, 2011. Further review revealed there were twelve (12) patients admitted to the hospital in May, 2011. There were twenty-one (21) patients admitted into the hospital in June of 2011. There were twenty-three (23) patients admitted into the hospital in July, 2011. Further review revealed there was missing data regarding whether or not R#8 had an organism/infection prior to being admitted in July 14, 2011. There were nineteen (19) patients admitted into the hospital in August of 2011. There were twenty-eight (28) patients admitted into the hospital in September, 2011. There were twenty-four (24) patients admitted into the hospital in October of 2011.

During the same interview on 11/16/11 at 10:30 a.m., S2DON confirmed there were sections that were left blank on the form indicating whether or not the patients were admitted with an organism/infection or were not recorded by the Nurse Liaison for R#7 and R#8 from April of 2011 to October of 2011. The DON indicated the "Infection Control Log" was inaccurate and not kept up-to-date from April of 2011 through October of 2011 as per protocol.

3)
Review of the laboratory culture results from the contracted laboratory service revealed there were a total of one hundred and thirteen cultures collected from urine, wound, blood and/or sputum were resulted from April of 2011 through October of 2011. Further review revealed there were a total of twenty (20) cultures collected from nine (9) urines, five (5) wounds, four (4) blood specimens, and two (2) sputums that read, "Not Done" on the laboratory reports for the month of April. There were a total of twenty-nine (29) cultures collected from five (5) urine samples, nine (9) wounds, and two (2) sputums reports that read, "Not Done" for the month of May. There were a total of eight (8) cultures collected from four (4) urine samples, two (2) wounds, and two (2) sputum specimens that read, "Not Done" on the laboratory reports for the month of June. There were a total of nine (9) cultures collected from six (6) urine samples, one (1) wound, and two (2) sputum specimens that read, "Not Done" for the month of July. There were a total of twelve (12) cultures collected from nine (9) urine samples, two (2) wounds, and one (1) sputum specimen that read, "Not Done" on the laboratory reports for the month of August. There were a total of nineteen (19) cultures collected from twelve (12) urine samples, three (3) blood specimens, and four (4) sputum specimens that read, "Not Done" for the month of September. There were a total of sixteen (16) cultures collected from eleven (11) urine samples, two (2) wounds, one (1) blood specimen, and two (2) sputums that read, "Not Done" on the laboratory reports for the month of October.

In the same interview on 11/16/11 at 10:30 a.m., S2DON verified there were a total of 274 culture results that were not done for the patients from April of 2011 through October of 2011. S2 denied knowledge why the culture results were incomplete from April through October. The DON indicated there is a break in the reporting system for all laboratory cultures collected from April through October of 2011.

4)
Review of the "Infection Control Function Report" and Laboratory Culture Results revealed there was no tracking and trending for the forty-two (42) cultures collected in April of 2011. There was no tracking and trending for the fifty-seven (57) cultures collected in May, 2011. There was no tracking and trending for the thirty-one (31) cultures collected in June of 2011. There was no tracking and trending for the twenty-seven (27) cultures collected in July, 2011. There was no tracking and trending for the twenty-six (26) cultures collected in August of 2011. There was no tracking and trending for the forty five (45) cultures collected in September, 2011. There was no tracking and trending for the forty-six (46) cultures collected in October of 2011.

During the same interview on 11/16/11 at 10:30 a.m., S2DON verified there was no documented evidence of tracking and trending for the forty-two (42) cultures collected in April, for the fifty-seven (57) cultures collected in May, for the thirty-one (31) cultures collected in June, for the twenty-seven (27) cultures collected in July, for the twenty-six (26) cultures collected in August, for the forty five (45) cultures collected in September, and/or for the forty-six (46) cultures collected in October. S2DON indicated there is no system in place to identify whether or not the patients had a community acquired infection and/or hospital acquired infection during their hospitalizations from April of 2011 through October of 2011.

5)
Review of the credentialing file for S4MD revealed no documented evidence of a current TB skin test.

Review of the credentialing file for S5MD revealed a document of a TB skin test administered on 04/05/11 and read on 04/08/11. There is no documentation to indicate the time administered or read to ensure compliance with the CDC Guidelines that the test be read within 48 - 72 hours.

Review of the personnel record for S1Administrator revealed a document of a TB skin test administered on 08/17/11 and read on 08/19/11. There is no documentation to indicate the time administered or read to ensure compliance with the CDC Guidelines that the test be read within 48 - 72 hours.

Review of the personnel record for S10RN revealed a document of a TB skin test administered on 08/01/11 and read on 08/03/11. There is no documentation to indicate the time administered or read to ensure compliance with the CDC Guidelines that the test be read within 48 - 72 hours.

In an interview on 11/16/11 at 10:38 a.m. with S3ADON she confirmed the above findings.

Review of the "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005" published by the CDC (Centers for Disease Control) revealed, in part, "...HCWs (health-care workers) refer to all paid and unpaid persons working in health-care settings who have the potential for exposure to M. tuberculosis through air space shared with persons with infectious TB disease. Part time, temporary, contract, and full-time HCWs should be included in TB screening programs. All HCWs who have duties that involve face-to-face contact with patients with suspected or confirmed TB disease (including transport staff) should be included in a TB screening program. The following are HCWs who should be included in a TB screening program: Administrators or managers...Nurses...Physicians (assistant, attending, fellow, resident, or intern)...".

Based on record review and interview the hospital failed to track indicators regarding infection control as evidenced by having no documented evidence the two hundred and seventy-four (274) cultures collected and reported by the contracted laboratory were tracked and trended from April of 2011 through October of 2011. Findings:


Review of the "Infection Control Function Report" and Laboratory Culture Results revealed there was no tracking and trending for the forty-two (42) cultures collected in April of 2011. There was no tracking and trending for the fifty-seven (57) cultures collected in May, 2011. There was no tracking and trending for the thirty-one (31) cultures collected in June of 2011. There was no tracking and trending for the twenty-seven (27) cultures collected in July, 2011. There was no tracking and trending for the twenty-six (26) cultures collected in August of 2011. There was no tracking and trending for the forty five (45) cultures collected in September, 2011. There was no tracking and trending for the forty-six (46) cultures collected in October of 2011.

During an interview on 11/16/11 at 10:30 a.m., S2DON verified there was no documented evidence of tracking and trending for the forty-two (42) cultures collected in April, for the fifty-seven (57) cultures collected in May, for the thirty-one (31) cultures collected in June, for the twenty-seven (27) cultures collected in July, for the twenty-six (26) cultures collected in August, for the forty five (45) cultures collected in September, and/or for the forty-six (46) cultures collected in October. S2DON indicated there is no system in place to identify whether or not the patients had a community acquired infection and/or hospital acquired infection during their hospitalizations from April of 2011 through October of 2011.