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Based on interview and record review, the facility failed to maintain an active hospital wide Infection Control Program for the prevention, control and investigation of infections. Resulting in the increased potential for increased risks of infections for all patients treated in the facility.

See specific A tag:


A-749: Failure to monitor and consistently conduct active surveillance activities.
A-756: Failure to ensure that problems (hand hygiene and personal protective equipment) with staff non-compliance identified by the infection control officer were addressed by the quality improvement committee

Based on interview and record review, the facility failed to ensure that a program for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was in effect resulting in the potential for increased infections in the facility and the potential for spread of infection and disease to patients and staff.

Findings include:

A review of the Infection Control Program was conducted on 11/28/17 at approximately 1100 with Infection Control Nurse Staff C and the Director of Quality Management Staff A.
Staff A explained the Quality Improvement Committee met monthly to review Infection Control findings. Staff C said there was an Infection Control committee that met monthly. She said the Infection Control Consultant (Staff K) was present those meetings.

When queried regarding hospital-wide infection prevent and control practices, Staff C explained that she was not required to mitigate patient infections that were present upon admission. Staff C said she only tracked hospital acquired infections.

Staff C said that Dietary Services nor Housekeeping Services were on the Infection Control committee. When asked to explain who monitored staff performance for infection control prevention and staff call-ins for Dietary services Staff C said that department would monitor their own staff. When asked to provide dietary surveillance activities and monitoring for dietary and nursing staff call-ins Staff C said that she did not have any. She said the HR (human resource) department may have had that information. However, evidence of monitoring of staff call-ins and infection control audits for the dietary staff were not provided to the surveyor prior to the survey exit.

A review of Infection Control meeting minutes revealed the following:
On 3/1/17, the facility had a Clostridium Difficile (C-Diff, highly contagious bacterial infection transmitted via stool) infection rate of 13.3 percent (%). Staff C said the facility had exceeded the targeted bench mark of 6.8%.
When asked to explain what corrective measures were implemented to decrease the rate of C-Diff infections, Staff C said concerns were discussed in a "Huddle" during morning rounds. Staff C stated, "I have an inservice in progress now for C-Diff". Staff C said it was possible that those patient's did not acquire the infections and that those patient's may have had C-Diff prior to admission. Staff C said RCA (root cause analysis) reflected nursing staff did not relay patient frequent stool occurrences to the physician nor the Infection control staff members.
Additionally, there were no corrective measures implemented for the identified infections.
When queried Staff C explained Dietary and Housekeeping service were not included in the monthly meetings.

On 4/5/17, the infection control meeting minutes did not document infection rates.

On 5/3/17, the facility had a C-Difficile infection rate of 12.9 percent (%). Staff C said "I had the housekeeping staff add bleach to the water for mopping the floors."

There were no infection control meetings in June or July 2017.

The infection control meeting minutes dated 8/9/17 did not address infection rates in the facility.

There were no infection control meetings in September. Staff C said the infection rate for C-Diff was 13.6 %. However, there were no corrective measures documented.

There were no infection control meeting in October. However, Staff C said the infection rate for VRE (vancomycin-resistant enterococci) infection was 1.2 %, and multi drug resistant organism (MDRO) infection rate was 2.5%.
There were no corrective measures documented for the identified infections.

A review of the facility's Annual Infection Control Risk Assessment dated 2017 documented the following:
C-Diff was at high risk with a likely probability. Strategies for Improvement: Implement C-Diff plan. Follow up with Environmental Services for housekeeping fill in. Utilize C-Diff leader for isolation compliance. Staff C explained the C-Diff plan was just implemented in October 2017 and was still in progress. When asked to explain why those measures were not implemented prior to October 2017, Staff C stated, "The C-Diff infection in September triggered this inservice."

On 11/29/17 at approximately 1355, housekeeping Staff L was interviewed. When queried regarding Infection Control inservices and education, Staff L explained she had worked in her role for approximately 4 years. Staff L said she could only recall having had an infection control education at around the time of hire.

On 11/29/17 at 1400 an interview was conducted with the Consultant Infection Control Officer Staff K. Staff K was asked if he reviewed the infection control meeting minutes and surveillance activities. Staff K said the Infection Control Program was combined with the Quality Improvement Program. Staff K said "there is no Infection Control Committee." Staff K said he was aware of the findings. Staff K stated, "We have low infection rates at this facility." Staff K said there is always room for improvement.

Based on interview and record review the facility failed to ensure that problems (hand hygiene and personal protective equipment) with staff non-compliance identified by the infection control officer were addressed by the quality improvement committee and that corrective action in the problem areas were implemented resulting in the potential for increased infections to all patients in the facility.
Findings include:

A review of the Infection Control Program was conducted on 11/28/17 at approximately 1100 with Infection Control Nurse Staff C and the Director of Quality Management Staff A.
Staff A explained the Quality Improvement Committee met monthly. Staff C said that she reported the monthly surveillance activies to the Quality Improvement meeting monthly.

A review of monthly hand hygiene and PPE (personal protective equipment) audits documented the following:

March 2017:
Hand hygiene compliance: Nursing staff 67% (percent). Respiratory staff 83%.
PPE compliance: Nursing staff 79%.

April 2017:
Hand hygiene compliance: Nursing staff 71%. Respiratory staff 75%. Physician staff 83%.
PPE compliance: Nursing 57%. Nurse Assistants 67 %. Physicians 33%.

May 2017:
Hand hygiene: Nursing 63%.
PPE compliance: Nursing 29%. Nurse Assistants 60%. Rehab 38%. Respiratory 67%.

June 2017:
Hand hygiene: 60% Radiology. "Other Staff" 50%.
PPE compliance: Nursing 80%. Nurse Assistants "0%".

July 2017:
Hand hygiene: Respiratory 75%. Physicians 67%.
PPE compliance: Nursing 60%. Other staff 43%. "Unknown" staff 67%.

August 2017:
Hand hygiene: 80% nurse assistants. Physicians 80%.
PPE compliance: Nursing 80%. Nurse Assistants 67%. Rehab 22%. Respiratory 75%.

September 2017:
Hand hygiene: Nursing 86%. Physicians 67%.
PPE compliance: Nursing 50%. Physicians 50%.

October 2017:
Hand hygiene: Nursing 67%.
PPE compliance: Nursing 50%. Nurse Assistants 67%. Physicians 75%. Other staff 75%.

When asked to explain if the infection control meeting minutes were reviewed by the facility
's quality committee, both staff members (A and C) said yes simultaneously.
When queried about a lack of initiating a plan for improvement for hand hygiene and PPE compliance Staff C explained that she would correct the action upon occurrence with the offender. When asked to provide evidence that documented corrective actions were implemented for the aforementioned months, Staff C stated, "I only have an inservice that is in correctly in progress for C-Difficile (infection found in the stool)." When asked to explain if that included all departments Staff C said no.

Staff A was overheard as she stated, "I see what you mean", when queried regarding evidence that documented corrective measures that were implemented relative to staff non-compliance with hand hygiene and PPE requirements on 11/28/17 at 1150. When asked to explain the facility's target goal for staff compliance with hand hygiene and PPE Staff A said 100% is our goal for compliance.

On 11/28/17 at 1300 an interview was conducted with the Medical Director Staff H. He explained that he attended the Quality Improvement meeting montly. When asked if he was aware of the monthly hand hygiene and PPE surveillance results Staff H said "We are always working to improve in those areas." Staff H said, I'm sure Staff K can be more of assistance in that area. He's our Infection Control Officer.

On 11/29/17 at 1400 an interview was conducted with the Consultant Infection Control Officer Staff K. Staff K was asked if he reviewed the infection control meeting minutes. He said the Infection Control Program was combined with the Quality Improvement Program. When asked if he reviewed the aforementioned hand hygiene and PPE surveillance results he explained that he was aware. He said that he knew that Staff C was always on the physician's to be compliant. However, Staff K was unable to explain what there was no evidence that documented a corrective action plan for hand hygiene and PPE compliance hand been implemented for the affected problem areas.