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Based on observation, interview, and record review the facility failed to implement a hospital wide infection control program to prevent, control, and investigate infections and communicable disease and failed to maintain a sanitary environment to avoid transmission of infections.

The facility failed to:

1. Ensure that four (4) of 4 sampled patients (ID #s 1, # 2, # 3, # 4 ) admitted with suspected Tuberculosis (TB) were placed in effective Airborne Isolation. Negative Air Pressure Rooms were not monitored for proper operation per facility policy.

2. Conduct monthly infection control surveillance for 5 of 8 months (June, July, August, September, and October 2011) and develop an Infection Control Committee to analyze infection control data and
make recommendations per facility policy.

3. Maintain a sanitary environment to reduce the risk of infection transmission in 4 of 9 rooms (Rooms D, E, J, I) in the Intensive Care Unit (ICU).

4. Ensure staff properly disposed of personal protective equipment utilized for a patient (ID # 2) placed in Contact Isolation.

Findings include:

Intake # TX00155678

1.

Record review of the facility " Tuberculosis Exposure Log, " dated 2011 revealed listing of four (4) patients with suspected or confirmed TB:

Patient # 1: admitted to ICU on 01-13-12; TB confirmed on 01-22-12

Patient # 2: admitted to ICU on 01-18-12; history of TB; TB ruled out

Patient # 3: admitted on 10-26-11; TB suspected; TB ruled out

Patient # 4: admitted on 11-14-11; TB suspected; TB ruled out

Interview in 01-26-12 at 1:50 p.m.with the Interim Chief Nursing Officer (CNO) stated all 4 patients had been admitted with " Airborne Precautions " per facility policy.

Patient # 1:

Record review of Patient # 1 ' clinical record revealed a physician order dated 01-21-12 that read: " ...2). Also tell them (Hospital Administration) unacceptable that negative air pressure room not working if patient has TB. " Further review of Patient # 1 ' s clinical record revealed laboratory result that confirmed Patient # 1 had Tuberculosis. The lab result dated 01-22-12 read: " PCR (polymerase chain reaction) positive. " PCR is a lab test indicative of TB.

Interview on 01-26-12 at 1:15 p.m. with the Chief Operating Officer [COO] (ID # 50) she stated she became aware of issues with two (2) negative air pressure rooms in the ICU the previous Friday (1-20-12). The COO went on to say there were patients (ID # 1, # 2) in each of the negative pressure rooms in the ICU; each had the diagnosis of " rule out TB. " It was her understanding the Maintenance staff found the " dampers not opened " and corrected the situation.

The COO went on to say on Monday (01-23-12) she was informed by staff that the negative air pressure rooms in the ICU were " working intermittently. " She reported a contractor came to the facility on Wednesday (01-25-12) to inspect the negative air pressure rooms and a different contractor arrived on Thursday (01-26-12) to conduct additional inspections and testing.

Interview on 01-27-12 at 12:40 p.m. with the contractor (ID# 61) he stated when he arrived at the facility on 01-26-12 " the negative air pressure rooms in the ICU were not operating properly due to mechanical /maintenance issues. "

Interview with Maintenance Supervisor (ID # 52) on 01-26-12 at 2:15 p.m. he stated the negative air pressure rooms were checked daily but no logs were kept.

Interview on 01-27-12 at 2:25 p.m with Maintenance Staff (ID # 62) he stated he was the maintenance staff on duty " this past Saturday and Sunday (01-21-12 and 01-22-12). " He went on to say he did not check the negative air pressure rooms in ICU over the week-end because " no one called him about a problem. " He further stated that in the past the rooms were checked when maintenance was notified of a problem.

Record review of facility policy titled " Tuberculosis Exposure Control " policy, dated 05/2002, read on page 8: " monitoring of isolation rooms when used for airborne isolation should be done daily by the Maintenance Department and documented in a log maintained by the Maintenance Department .... "

Further review of this same policy on page 4 read: " ...All patients with suspected or confirmed pulmonary or laryngeal TB will be placed in airborne isolation until they are determined to be non-infectious. "

Review of facility policy titled " Plan: Isolation Precautions, " dated 5/2002 read on page 3 " ...1. a Airborne Precautions: place the patient in designated room that has monitored negative air pressure in relation to the surrounding air ... "

2.

Review of facility admission records revealed after a change in ownership, the facility admitted the first patient on 06-16-2011.

Review of the facility Infection Control Logs revealed infection data collected for the months of November and December 2011 and January 2012 (YTD). There were no infection control logs or data for June, July, September, and October 2011 available for review.

Interview on 01-26-12 at 1:50 p.m.with the Interim CNO (ID # 51) she stated she was also responsible for the Infection Control Program. She went on to say the Infection control program was begun in October 2011 and Infection Control logs were started in November 2011.

She went on to say the facility was in the process of establishing an Infection Control Committee but did not yet have one. Presently important information regarding infections was discussed but not through a formal infection control committee.

Record review of the facility " Infection Control Program " dated 2012 revealed " the Infection control Program. is implemented by members of the ..Infection Control Committee which included representation from the Hospital Medical staff, administration, and other supporting services. " Further review of the program revealed the facility performed monthly targeted surveillance that included device- related infections, infections resistant to antibiotics, other infections, environmental rounds, hand washing surveillances, and more.

3.

Observation during a tour of the ICU on 01-26-12 at 2:15 p.m. revealed the following environmental / infection control issues of rooms ready to receive new patient admissions:

Room D: (empty room): heavy dust on top of the cardiac monitor and a bottle of unopened IV Nitroglycerin labeled for a patient who had been previously discharged.

Room F: (empty room):heavy dust on top of the cardiac monitor ; suction canister 2/3 full of brownish colored liquid ; uncovered Ambu-bag hanging on the wall.

Room J (empty room): heavy dust on top of the cardiac monitor; soiled gloves and paper in an open trash can.

Room I (empty room): heavy dust on top of the cardiac monitor; Biohazard trash can ? full of trash.

Interview on 01-26-12 at 2:30 p.m. with ICU staff Registered Nurse (RN/ ID # 54) she stated " all the empty rooms through Room H are ready to receive patients. "

Interview on 01-26-12 at 2:35 p.m. with ICU staff Registered Nurse (RN/ ID # 53) she stated " all the empty rooms are fully stocked and ready. "

Interview on 01-26-12 at 2:15 p.m with Interim ICU Manager (ID # 55) he stated the rooms were not properly cleaned ts and the rooms would be re-cleaned by housekeeping.

4.

Patient # 2:

Record review of Patient # 2 ' s clinical record revealed he was admitted to the facility on 01-18-12 with Pneumonia, Altered Mental Status, Sepsis, and multiple severe Decubitus Ulcers.

Observation during a tour of the ICU on 01-26-12 at 2:15 p.m. revealed Patient # 2 laying in bed in Room A. On the door of the room was a sign that read: " Contact Precautions. " Interview with staff RN (ID # 53) at this same time revealed Patient # 2 was on Contact Precautions due to MRSA infection of his pressure ulcers. MRSA (Methicillin-Resistant Staphylococcus Aureus) is a bacterium responsible for difficult-to-treat infections.

Further observation at this same time revealed an " ante-room " connected to Room A, which was a negative air pressure room. A yellow paper isolation gown was observed located in an open trash can with ? the gown spilling over the top. Further observation revealed a soiled glove and paper towel located on the floor and 2 disposable masks hanging on an IV pole.

Interview with Interim CNO/ Infection Control Director (ID # 51) at the time of observation she stated the isolation gown, gloves, and paper towels should be disposed of in a covered Biohazard container and the respirator masks should be covered and labeled.