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Based on observations, interviews, policy reviews and records of hospital acquired infections the facility failed to avoid sources and transmission of infections and communicable diseases.

Findings include:

1 On 03/23/2010, at 12:30 noon LTAC Director of Clinical Services and surveyor were on the LTAC Hospital 2nd floor. At room 267, a hospital phlebotomist was noted leaving the room wearing gloves, mask, isolation gown and carrying her phlebotomist tray. Room 267 was noted by signage to be on Droplet and Contact Precautions. The phlebotomist placed the tray on the floor outside the door by the wall, the mask, gloves and gown were remove then rolled up and placed in the phlebotomist tray. The phlebotomist then picked up the tray and proceeded to walk down the hall. LTAC Director of Clinical Services interrupted the phlebotomist for disposal of the isolation attire.

At the above time the phlebotomist was asked why she placed the isolation attire in the phlebotomist tray and she reported that there was no place in the room to leave it.

LTAC Director of Clinical Services was asked about the above observation and reported that the attire should have been left in the room.

3 Review of the Greenwood Leflore Hospital Infection Control Standard and Transmission-Based Precautions procedure revealed that Personal Protective Equipment (PPE) will be donned (applied) before entering the room and will be doffed (removed) prior to leaving the room. (Phlebotomist is employed by Greenwood Leflore Hospital.)

Review of the LTAC Hospital of Greenwood procedure for Personal Protective Equipment (PPE) noted that PPE will be applied before entering the room and will be removed prior to leaving the room. (Observation of PPE violation was at Room 267 of the LTAC Hospital.)

4 On 03/23/2010, at 1:40 PM, interview with the Greenwood Leflore Hospital Infection Control Nurse revealed that all clinical areas of the Greenwood Leflore Hospital are inserviced on the Isolation Precautions and use of PPE.

The above phlebotomist on 03/17/2009, attended the hospital Infection Control Standard and Transmission-Based Precautions inservice.

5 On 03/23/2010, beginning at 11:30 AM, Accreditation Coordinator Director and surveyor toured LTAC Hospital on 2nd floor of the Greenwood Leflore Hospital. The tour revealed fourteen (14) rooms with signage for Contact and/or Droplet Precautions. LTAC is licensed for forty (40) beds and the census was twenty (20).

6 Review of the LTAC Hospital Infection Control Record of hospital acquired infections (HAI) from September, 2009 through February, 2010 of revealed:
2009
September four (4)
October two (2)
November two (2)
December ten (10)

2010
January five (5)
February six (6)

7 Review of the Greenwood Leflore Hospital Utility Systems air quality test and balance reports for the isolation rooms revealed no documented parameters, pass/fail scores or ranges present.

Review of Utility Systems EC.7.10.16, Policy on Installing and Maintaining Appropriate Pressure Relationships documents: It is the policy of the Greenwood Leflore Hospital that all ventilation systems shall be installed and maintained in a manner that will ensure that the appropriate pressure relationship, air exchange rates, and filter efficiencies for ventilation systems that serve areas specially designed to control contaminants. Effective Date: 03/01/2005.

Surveyor noted there were no documented parameters, pass/fail scores or ranges present in the policies either.

Infection Control Nurse when asked was unable to provide any documented parameters, pass/fail scores or ranges present in the policies or on the forms.

Based on interviews, physician order and nursing service policy review the facility failed to ensure that the physician order for wound cultures was carried out as ordered.

Findings include:

1 On 03/24/2010, at approximately 10:00 AM, Long-Tern Acute Care (LTAC) Hospital Infection Control Patient Data Tool record review of a 01/07/2010 admission revealed a sacrum culture report of 01/30/2010.

2 On 03/24/2010, at approximately 2:00 PM, medical record review of the same 01/07/2010 admission revealed:

a Cultures ordered 01/07/2010 by the physician.
b Nurses notes noted 01/07/2010 at 2:30 PM pictures and cultures done per the wound care nurse.

3 On 03/24/2010, at 3:30 PM, interview with LTAC Hospital Director of Clinical Services reported that they had been unable to locate any results for the 01/07/2010 wound culture order and that the laboratory was unable to verify any receipt of a wound culture of 01/07/2010. Director reported that the wound care nurse was unable to remember whether they were completed or not and thus the order was written again for 01/30/2010, which was completed and resulted.

4 On 03/24/2010, at approximately 3:30 PM, interview with the wound care nurse confirmed that she was unable to remember whether the cultures were completed or not.

5 On 03/24/2010, at approximately 3:30 PM, the 24 Hour Chart Check policy was reviewed and noted that the 24 hour chart check will be performed on every chart during the night shift. Further noting that orders should be carefully checked and their executions confirmed.