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Based on review of infection control logs, review of employee files, observation and interviews the hospital failed to have a have a sanitary environment to prevent the transmission of infectious and communicable diseases. The hospital failed to have an active program for the prevention, control and investigation of infectious and communicable diseases.

Findings include:

Infection Control Practioner (ICP) failed to develop a system for identifying, reporting and investigating infections and communicable disease for their personnel. (A 748)

The hospital failed to develop a system for identifying, reporting, investigating and controlling infectious and communicable diseases for both patients and personnel. (A 749)

The Infection Control Program (ICP) failed to include employees and when an outbreak of scabies was identified the ICP failed to maintain a log of the outbreak to include both patients and staff. (A 750)

The Chief Executive Officer (CEO), the medical director and the director of nursing services failed to be responsible, once the hospital became aware of a scabies outbreak starting in August 2009. The hospital did not take corrective action to ensure that both patients and staff who were potentially exposed were monitored and treated. The hospital did not notify the appropriate public health agencies in order to receive support, recommendations and ensure up to date information was provided. (A756)

The accumulative effects of these systematic failures prevented the hospital from maintain and active and effective Infection Control Program.

Based on observation and staff interview the hospital failed to ensure security of medical records for 19 of 19 patients.

Findings include:

On 03/11/10 during observation at the hospital's secondary (off site) location, Surveyor #22198 observed 19 of 19 nurse servers that housed the patients complete medical record were located in the public hallway. All 19 nurse servers were unlocked.

On the morning of 03/11/10 these findings were acknowledged by Registered Nurse (RN) Director of Clinical Services J, and the current hospital census of 19 pt. was confirmed.

On the afternoon of 3-11-2010 at the exit conference CEO A had no additional information.

Based on patient interview and record review the hospital failed to meet patients (pt) needs for hygiene care and answering call lights for 3 out of 6 (#4, #6, #9) patients interviewed.

Findings include:

On 3-11-2010 at 12:50 PM review of medical record for pt. #4 revealed on 3-1-2010 and 3-2-2010 no documentation of any hygiene completed for this pt.

On 3-11-2010 at 1:10 PM review of medical record for pt. #9 revealed on 3-3-2010 and 3-8-2010 no documentation of hygiene completed for this pt.

On 3-10-2010 at 10:20 AM interview with pt. #4 revealed she had been at the hospital for two weeks. Pt. #4 stated that there are times when it takes staff awhile to answer her call light. Pt. #4 could not give anymore specific information.

On 3-10-2010 at 10:25 AM interview with pt. #6 revealed she had been at the hospital for three to four weeks. Pt. #6 stated that sometimes it take awhile for staff to answer her call light, " I peed in bed about 3-4 times " waiting for staff to answer call light. Pt. #6 stated that the bed linens are changed daily and the incontinent pad is changed daily and, " with every accident " . Pt. #6 stated that staff are trying hard and when it takes awhile to answer her call light they apologize saying, " sorry, we are short of help. " Pt. #6 is not sure of exact dates when the hospital has not been staffed sufficiently.

On 3-10-2010 at 12:36 PM interview with pt. #9 revealed she had been at the hospital for about two and a half weeks. Pt. #9 stated that there are times that it takes awhile for staff to answer her call light and she does hear staff saying they are short of staff. Pt. #9 explained that the bed linens are changed daily but she would like her hair washed every week, unsure the last time it was washed. Pt. #9 also stated the hallways are often cluttered. Pt. #9 is unsure of the dates when the hospital was not staffed sufficiently.

On the afternoon of 3-11-2010 at the exit conference CEO A had no additional information.

Based on interview and record review the ICP(Infection Control Practitioner) failed to develop a system for identifying, reporting and investigating infections and communicable disease for their personnel.

Findings include:

On 03/10/10 at 1:00 p.m. Quality Assurance Program Improvement (QAPI) Director B told Surveyor #22198, that the Infection Control Practioner (ICP) was Staff N. Staff N was responsible for the infection control program for staff and patients.

On 03/11/10 at 10:00 a.m. Infection Control Practioner (ICP) N confirmed to Surveyor #22198 during an interview that she does not include employees in the infection control program.

ICP N told Surveyor #22198 that she only worked 2 days a week and was hired to maintain an infection control program for their patient population.

During an interview with QAPI B and Director of Clinical Service (DOCS) C, confirmed that the hospital was aware of staff potentially having scabies in late July or early August of 2009, however the hospital, based on a communicable disease reporting sheet, (provided to Surveyor #22198) did not notify public health.

Neither QAPI Director B nor DOCS C knew where the communicable disease reporting sheet came from, however it did not reflect the public health reporting requirements or Chapter 145 Appendix A "Communicable Disease and Other Notifiable Conditions, Register, February 2008, No. 626.

Neither QAPI Director B nor DOCS C contacted the Public Heath department to report the scabies or seek advice on diagnosing, treatment or prevention of the further spread of scabies. Also present during this interview and review of hospital data was Chief Executive Officer (CEO) A.

On 3/11/10 surveyor #22198 spoke with Department of Health Communicable Disease Contact AA, who confirmed an outbreak of scabies within the hospital should have been reported.

On 03/11/10 during exit conference with CEO A, QAPI Director B, and DOCS C, it was confirmed the hospital failed to include employees in their Infection Control Program. Furthermore the hospital failed to include current and discharged Patients in the review and treatment of scabies (a communicable disease).

Based on interview the hospital failed to develop a system for identifying, reporting, investigating and controlling infectious and communicable diseases for both patients and personnel.

Findings include:

On 03/11/10 at exit conference it was discussed and determined that:

One staff complained of symptoms and sought treatment for scabies August of 2009.

Five staff complained of symptoms and sought treatment for scabies in September 2009.

Twelve staff complained of symptoms and sought treatment for scabies in November 2009, before the hospital took action. The hospital offered staff and staff family ' s treatment, but no assessments or treatment was offered or provided to the hospital's patients at that time.

The hospital failed to track this outbreak to determine the source, or identify discharged patients who may have been affected to notify them.

From 03/10/10 through 03/11/10 Surveyor #22198 along with Infection Control Practioner (ICP) N and Director of Quality Improvement (QI) B through investigation and information gathering noted from August of 2009 through November 2009 a total of 17 staff complained of scabies like symptoms and were treated, however the hospital failed to complete an investigation of all employees, to include documentation from the staffs Primary Care Physicians (PCPs), to confirm and monitor and control further outbreaks.

Director of QI B confirmed the hospital failed to report the scabies outbreak to the local public health department, based on "Transmission Based Precautions" (total of 9 pages), the Director of QI B was uncertain where the document was obtained from.

Director of QI B acknowledged that this 9 page document failed to identify the source from where the reporting requirements was obtained, or the standard of practice it was following, and that this documented was not dated to identify if this information was current.

In November 2009 the hospital purchased medicated cream to treat the staff, however the hospital failed to include the ICP(Infection Control Practitioner) N or the Infectious Disease Physician O. The patients were never notified of the outbreak or included in the monitoring to determine if any of the patients had been effective or exposed to scabies.

On 03/11/10 at 9:30 a.m. during a telephone interview with Department of Health Communicable Disease Contact AA, told Surveyor #22198, that if exposure to scabies is for the first time, it could take several weeks before the scabies signs and symptoms were noticed. If a patient or staff had been exposed before, it might only take 3 to 5 days.

Department of Health Communicable Disease Contact AA told Surveyor #22198, that under Chapter 146 State reporting requirements for Communicable Disease, scabies is not listed under category I or II. However under Category I, there is a statement that says: "Outbreaks, suspected or other acute and occupationally related diseases", based on this requirement AA confirmed to Surveyor #22198, scabies should have been reported.

Department of Health Communicable Disease Contact AA told Surveyor #22198 that scabies is skin to skin contact, and that anyone who was in contact with staff or patients who had scabies, should be treated, and monitoring should be done.

During the exit conference on 03/11/10 Chief Executive Officer A, Director of QI B and DOCS C confirmed the hospital had failed to report the scabies outbreak, failed to have a system in place to include surveillance and treatment of scabies, failed to treat patients and families that may have been exposed, and failed to monitor further to prevent further exposure and control of the communicable disease.

Based on review of the infection control log the Infection Control Program (ICP) failed to include employees and when an outbreak of scabies was identified the ICP failed to maintain a log of the outbreak to include both patients and staff.

Findings include:

On 03/11/10 at 10:00 a.m. Infection Control Practioner (ICP) N confirmed to Surveyor #22198 during an interview that she does not include employees in the infection control program.

On 03/10/10 at 1:00 p.m. Quality Assurance Program Improvement (QAPI) Director B told Surveyor #22198, that the Infection Control Practioner (ICP) was Staff N. Staff N was responsible for the infection control program for staff and patients; however after an interview with ICP N, QAPI B confirmed the hospital only tracked employee infection via sick "call ins". QAPI Director B, provided to Surveyor #22198 a hand written list of 17 employees who had scabies like symptoms and were treated by offsite physicians. The hand written document did not match the sick call list. QAPI Director B acknowledged to Surveyor #22198, that she had put together the hand written list of the 17 employees today, however could not confirm the accuracy of the approximate dates since the hospital did maintain a list for their employees.

QAPI Director B told Surveyor #22198, that she was responsible for maintaining the employee sick list; however it did not include trending patterns of infections or communicable diseases.

Review of employee files 03/10/10 through 03/11/10 failed to include health information from the staff ' s primary care physicians regarding scabies exposure. QAPI Director B, acknowledged that the hospital failed to maintain accurate and complete health information for its employees after the scabies outbreak was identified in August, September and again in November.

QAPI Director B confirmed to Surveyor #22198, the hospital had failed to include their Infection Control Practioner (ICP) N or their Infectious Disease Physician O in the scabies outbreak. Therefore patients who were admitted prior to the identified outbreak, those in-patient during August, September and November 2009 were not monitored or log to ensure they had not been exposed.

QAPI Director B confirmed to Surveyor #22198, there was no formal log to identify the scabies outbreak.

Based on review of infection control data and staff interviews the Chief Executive Officer (CEO), the medical director and the director of nursing services failed to be responsible, (once the hospital became aware of a scabies outbreak starting in August 2009). The CEO, the medical director and director of nursing failed to ensure corrective action was taken to make certain that both patients and staff who were potential exposed were monitored and treated and the appropriate public health agencies were notified.

Findings include:

On 03/10/10 through 03/11/10 Surveyor #22198 along with Director of Quality Assurance Program Improvement (QAPI) B reviewed the information that pertained to a complaint of a scabies outbreak in August 2009.

Director of QAPI B confirmed the hospital failed to log and monitor its staff for all infectious and communicable diseases.

Director of QAPI B confirmed the hospital was aware of the scabies outbreak, however because the hospital did not maintain logs or surveillance there was not documentation of a specific date. After several months starting with August and September 2009 when staff were reporting they had scabies like symptoms, in November 2009 the hospital purchased medicated cream to treat all its staff, however failed to treat any of its past or current patient and failed to implement this scabies outbreak into the infection control program to ensure that the appropriate steps were being taken based on the current standards of care and reporting requirements.

On 03/11/10 during the exit conference Chief Executive Officer A, along with Director of QAPI B and Director of Nursing (DOCS) C acknowledged all findings.