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Based on review of records and interviews, the facility did not designate an infection control officer to implement policies governing control of infections and communicable diseases.

Findings include:

Review of Infection Control Log sheets and Infection Control Reports for this year, showed the hospital had no documentation by an infection control officer during the months of May, July and August 2010.

In a telephone interview the afternoon of 09/30/10 with Personnel #6, when asked if she was the Infection Control nurse, she said "no." She stated that she had tracked hospital infection control issues starting in October 2009 when she became the Assistant Director of Nurses (ADON), but had stopped when a new ADON, Personnel #5, had been hired in either May or June 2010. Personnel #6 said she had only tracked "core measures" since that time, and that she did not know if any other infection control processes were currently being done.

In a telephone interview the afternoon of 09/22/10 with Personnel #1, when asked if the facility had a current infection control officer, he said "no." He stated that the ADON, Personnel #5, had worked her last day on 07/28/10, and they did not have a new infection control officer.

Based on review of records, and interviews, the facility infection control officer had not maintained a log of incidents related to infections and communicable diseases, in that, 1 of 1 patients isolated for possible Methicillin-Resistant Staphylococcus Aureus (MRSA) was not documented in the hospital Infection Control Log or in Infection Control Reports for May, July or August 2010.

Findings include:

The medical record for Patient #1 noted that she had been admitted to Room 206-A on 07/21/10 with a diagnosis of "Uncontrolled Diabetes Mellitus, Possible MRSA, Infected sores, and Candidiasis." The patient was noted to have a "severe fungal rash with open blisters under bilateral breasts," and "a skin rash with lesions all over upper torso." The physician wrote that "she is suspected to have Staphylococcus infection," and the patient was placed in Contact Isolation, consistent with MRSA infection control requirements. She was started on oral and intravenous antibiotics.

The facility "MRSA (Methicillin-Resistant Staphylococcus Aureus) Protocol, Infection Control" policy, last approved 03/12/07, noted that: -"MRSA Infections with external body fluid secretions will be placed in Contact Isolation."

In a telephone interview the afternoon of 09/30/10 with Personnel #6, when asked if she was the Infection Control nurse, she said "no." She stated that she had tracked hospital infection control issues starting in October 2009 when she became the Assistant Director of Nurses (ADON), but had stopped when a new ADON, Personnel #5, had been hired in either May or June 2010. Personnel #6 said she had only tracked "core measures" since that time, and that she did not know if any other infection control processes were currently being done.

In a telephone interview the afternoon of 09/22/10 with Personnel #1, when asked if the facility had a current Infection Control Professional, he said "no." He stated that the ADON, Personnel #5, had worked her last day on 07/28/10. He confirmed that there were no Infection Control Reports for May, July and August 2010.

Although Patient #1 with suspected MRSA was placed in Contact Isolation, her diagnosis required that she be tracked by the infection control officer. The log was not maintained, in that, there was no record of this suspected infectious diagnosis or any other infection control issues tracked in the Infection Control Log that may have occurred during the months of May, July and August 2010.