HospitalInspections.org

25059

Based on record review, observation, and interview, the hospital staff failed to ensure the patient's right to personal privacy during medical/nursing treatments as evidenced by the door wide opened and the patient visibly lying in bed during dialysis treatments for one (#2) of 5 sampled patients (#1, #2, #3, #4, #5) and for one (R55) of 55 random sampled patients (R1 through R55) and when transferring a patient from the bed to a chair for rehabilitation treatment for one (#2) of 5 sampled patients, (#1, #2, #3, #4, #5). Findings:


Patient #2:

During a tour of the hospital on 08/21/12 from 9:45 a.m. through 10:00 a.m., Room "a" was observed with the door wide opened and the patient was in the bed lying on flat on her back. At 9:45 a.m., S5Rehab Tech, S6Therapy Director, and S7Rehab Tech were observed at the patient's (#2's) bedside moving the patient from the bed to a chair with the door wide opened from 09:45 a.m. through 10:00 a.m. during the transfer of the patient from the bed to the chair. At 10:00 a.m., the Therapy Director, S6 confirmed the patient (#2) was transferred from the bed to the chair with the door opened.

Another observation was conducted on 08/21/12 from 1:05 p.m. through 1:10 p.m., Room "a"'s door was observed wide opened with S8RN (registered nurse) Dialysis standing at the patient's bedside. Further observation revealed there was a dialysis machine noted next to the patient's bedside. At 1:05 p.m., S8RN Dialysis nurse was interviewed during this observation. S8RN indicated the patient (#2) was being dialyzed at this time with the door opened.

Random Patient #55 (R55):

Another observation was conducted from 1:33 p.m. through 1:55 p.m. on 08/22/12. Room "b"'s door was observed wide opened with a dialysis machine next to the patient's bedside. Further observation revealed the patient (R55) was lying flat on her back at this time. S9RN, Dialysis nurse was observed sitting the chair and typing on a laptop. At 1:50 p.m., S9RN, Dialysis nurse was interviewed. S9RN indicated the patient's (R55's) door was left opened for safety measures so that staff may respond faster during an emergency situation requiring immediate respiratory and/or cardiac arrest. At 1:55 p.m., the patient (R55) was not interviewable at this time.

In interviews on 08/22/12 at 1:40 p.m., and at 1:45 p.m., S10LPN (licensed practical nurse), S11RN, and S12RN indicated patient doors must be closed during any medical/nursing treatments to respect the patient's privacy including dialysis treatments and/or transferring a patient from the bed to the chair for therapy as per policy.

The policy titled, "Patient Rights & Responsibilities", Policy Number: XI.A.11.0, Approval date of 08/2012, Effective date of 2007, Reviewed date of 02/2012, with no revised and/or retired dates, revealed the policy indicated upon admission to the facility, a patient will be provided a copy of the Patient Handbook which will be reviewed with the patient/support person to include but not limited to the Patient Rights and Responsibilities.

Review of the handbook titled, "A Guide To Patient Services", Notice of Privacy Practices, section titled, "Patient Rights" with no page number read, "As a patient in our hospital, you have the right to considerate, respectful care in a safe setting with recognition of your personal dignity and respect for your privacy concerning your medical care concerning your hospitalization".

25059

Based on record review and interview, the hospital failed to have a system in place for identifying, reporting, investigating, and controlling infections and communicable diseases of patients from January through August of 2012 as evidence by:

1) failing to have accurate documented evidence

a) To identify whether the patient's infections were healthcare-associated infections (HAIs) and/or community acquired infections (CAIs) recorded on the "Infection Control Surveillance Sheets" (tool used by the facility to capture data relating to Infection Control) for patients identified with having an infection from January 2012 - August 2012.

b) To accurately identify patient's with organisms on admission from January 20-12 - August 2012.

c) To accurately identify and record results of labs and/or cultures taken by the facility from January 2012 - August 2012.

In an interview on 08/23/12 at approximately 1:08 p.m., S3ICP (infection control practitioner) indicated she does not track, trend, monitor, and analyze infections since her date of hire as ICP on 11/15/11. During the above interview S3 indicated she kept a patient surveillance sheet on each patient to document infections, the appropriateness of the antibiotics used and note if the infection was health care acquired or community acquired..

During an interview on 08/24/12 at 12:45 p.m., S4Quality Manager confirmed there was inaccurate data collected on the "Infection Control Surveillance Sheets" from January through August of 2012. The Quality Manager indicated there was inaccurate tracking, trending, measuring and analyzing infectious diseases from January through August of 2012.

25059

Based on record review, observation, and interview, the Registered Nurse failed to supervise and evaluate the nursing care for each patient as evidenced by failing to assess and implement Contact and Droplet Precaution protocols for a patient admitted with a sputum culture positive with Methicillin-resistant Staphylococcus aureus (MRSA) and Klebsiella organisms from 08/02/12 through 08/16/12 and on 08/20/12 for one (#4) of 5 sampled patients. Findings:

During a tour of the hospital conducted on 08/21/12 from 9:30 a.m. through 11:27 a.m. and on 08/22/12 at 10:45 a.m., Room "c"'s door was observed opened with a sign posted on the door labeled, "Contact Precaution" that had a red "STOP" sign that read, "Visitors must go to the nursing station before entering room. Wash hands with soap and water and/or hand sanitizer prior to entering or leaving the room. Wear gloves and gown when entering room. At 9:45 a.m., Room "a"'s door was observed with a sign labeled, "Contact Precautions Enhanced" that read, "Visitors must go to the nursing station before entering room...Wash hands with soap and water prior to entering or leaving the room. Wear gloves when entering room. Wear gown when entering room".

At 9:50 a.m., there were three (3) student nurses observed donning gloves and gowning outside of the door of Patient #2's door, Room "a". Further observation revealed there was no hand sanitizer station located in the hallway. The nearest hand sanitizing station was located at the nurses station twenty (20) feet in distance from Room "a:. There was no observation of the student nurses performing handwashing prior to entering into the patient's (#2's room, Room "a"). Further observation revealed S14CNA (certified nursing aide) was observed entering into Room "a", walked to Patient #2's bedside, and a family member, who was sitting in a chair located up against the wall was observed not wearing a gown and/or gloves, requested a pair of socks for Patient #2. At this same time, S14CNA was observed exiting the patient's (#2's) room without performing donning a gown and/or gloves, and/or performing hand washing. S14CNA walked to the nurses station at this time. At 9:53 a.m., S14CNA was observed entering Room "a", handed Patient #2 a pair of socks, and exited the room (Room "a") without donning a gown and/or gloves and/or performing handwashing. On 08/22/12 at 10:45 a.m., a family member was observed sitting in the chair located by the window with no gown and/or gloves donned.

On 08/21/12 at 10:25 a.m., Room "d"'s door was observed opened, a sign posted on the door labeled, "Contact Precaution", a student practical nurse, S15 degowning and degloving, and exited the patient's (R21's) room (Room "d") without performing handwashing. At this time, S15 was interviewed and confirmed she did not perform handwashing prior to exiting the patient's (R21's) room as per protocol.

During another tour of the unit on 08/22/12 from 9:30 a.m. through 9:55 a.m., Room "d"'s door was observed with a sign posted on the door labeled, "Contact Precautions". Further observation revealed S5Rehab Tech opened the closed door, walked approximately fifteen (15) feet into the patient's (#1's) room, and exited the room without donning gloves and/or a gown and/or performing handwashing prior to entering and/or exiting the patient's (#1's) room (Room "e"). At 9:45 a.m., Room "f"'s door was observed opened with a sign posted on the door labeled, "Contact Precaution".

Further observation revealed S16Housekeeper was observed entering the patient's (R56's) room (Room "f"), donning gloves, got the bag of trash from the trashcan located inside the room by the sink area, walked out of the room with the bag of trash to a grey container located next to Room "g", threw the bag of trash into the container, removed left glove and threw it into the gray container, pushed the grey container to the dirty utility area wearing the right hand glove, removed two (2) bags of trash laying on top of the trash in the gray container, threw them into an unlabeled gray cart, removed a red trash bag from the container and discarded it into a red container labeled, "Biohazard", and discarded her right glove into the grey container without performing handwashing. At 9:55 a.m., the Housekeeper, S16 was observed pushing the grey container to Room "g", touched the clean utility cart linen, and handsanitized with the cleanser on her cart. At this time, S16Housekeeper indicated she had been a Housekeeper for the hospital for eight (8) or nine (9) years. S16 denied knowledge the sign read, "Wash hands with soap and water, Don gown upon entering the room". The Housekeeper, S16 confirmed she did not wear a gown upon entering Room "g" and/or performed handwashing prior to exiting Room "g" as per protocol.

On 08/22/12 from 10:45 a.m. through 11:11 a.m., Room "c"'s door was observed opened with a sign labeled, "Contact Precaution". Further observation revealed there was a visitor/family member standing at Patient #4's bedside with their arms resting on the bedrail without donning gloves and/or a gown.

Review of the "Laboratory Gram Stain" report dated/timed 08/02/12 at 11:50 p.m. (2350)-eight (8) hours after admission revealed Patient #4 had respiratory cultures positive with Methicillin Resistant Staphylococcus aureus (MRSA) and Klebsiella pneumoniae organisms.

The medical record for the patient (#4) was reviewed and revealed an admission date on 08/02/12 with no discharge date recorded on the form-the patient was in the hospital's census on 08/24/12. Further review of the "Physician Admission Orders" dated/timed 08/02/12 at 3:00 p.m. (1500) revealed Patient #4's was admitted with the following diagnosis: Resp. (Respiratory) Failure Vent (Ventilation) Dependant, and Anoxic Brain Injury. The patient's (#4's) Code Status was full code with no documentation of "Isolation"-this section was blank on the form. Review of the "Pre-Admission Evaluation Summary" dated 07/31/12 revealed Patient #4 was positive for MRSA. Further review revealed there was no documented evidence of Patient #4's positive respiratory culture positive with Klebsiella pneumonaie organism after admission at 11:50 p.m. (2350)-eight (8) hours after admission on 08/02/12.

Review of the "Interdisciplinary Admission Assessment (IAA)-Nursing dated 08/02/12 at 3:20 p.m. (1520) revealed Patient #4 was admitted into the hospital by the nursing staff (Laisson nurse, registered nurse). Further review revealed there was no documented evidence the nursing staff (registered nurses) documented, supervised, assessed, evaluated, identified, and/or implemented the Contact and Droplet Precautions for Patient #4 as per protocol-the following sections titled, "Present Illness", "Previous Hospitalizations/Surgeries", "Health History", and/or "Respiratory" had no documented evidence of the sputum and nasal swab positive with MRSA and Klebsiella organisms were identified after patient (#4) was admitted into the hospital at 3:20 p.m. (1520) and the cultures were resulted at 11:50 p.m. (2350)-eight (8) hours after admission on 08/02/12.

Further review of the "Interdisciplinary Patient/Family Education" Plan of Care revealed no documented evidence the registered nurse supervised, assessed, evaluated, identified, and/or implemented measures addressing Patient #4's sputum and nasal swabs positive with MRSA and Klebsiella organisms from 08/02/12 to 08/15/12 and/or on 08/20/12 as per the Contact and Droplet Prevention protocols.

The "Infection Control Surveillance Sheet" revealed Patient #4 was admitted on 08/02/12 with no discharge date documented-the patient was on the hospital's census as of 08/24/12. Further review revealed Patient #4 was admitted with sputum and nasal swab positive with MRSA organism on admission. The Infection Control Practitioner (ICP), S3 reviewed Patient #4's "Surveillance Sheet" on 08/06/12 and 08/14/12-this was handwritten on the top right corner of the sheet. The section titled, "Precaution: Contact was circled on the sheet indicating the patient (#4) was on Contact Precautions. Further review revealed there was no documented evidence S3ICP's identified Patient #4 was on Droplet Precaution-this section was left blank on the form as of 08/24/12 as per protocol from 08/02/12 to 08/15/12 and/or on 08/20/12.

Further review of the "24 Hour Care Record-1"-nurses notes for the registered nurses revealed there was no documented evidence the nursing staff supervised, assessed, evaluated, and implemented the Contact and Droplet Precautions for Patient #4 from 08/02/12 through 08/15/12-fourteen (14) days and/or on 08/20/12 as per protocol.

In interviews on 08/22/12 at 1:10 p.m., on 08/23/12 at 9:15 a.m, and at 2:05 p.m. and on 08/24/12 at 9:15 a.m. , S2 Interim Director of Nursing confirmed Patient #4 was on "Contact Precaution" requiring all staff members to perform handwashing with soap and water prior to exiting the room and donning gloves and gowns as per protocol. The Interim Director of Nursing, S2 verified Patient #4 had MRSA and Klebsiella organisms on admission on 08/02/12 requiring both Contact and Droplet Precautions to be implemented by all staff. S2 confirmed there was no documentation the registered nurse supervised, assessed, evaluated, identified, and/or implemented measures addressing Patient #4's sputum and nasal swabs positive with MRSA and Klebsiella organisms from 08/02/12 to 08/15/12 and/or on 08/20/12 as per the Contact and Droplet Prevention policies. S2Interim Director of Nursing indicated all staff are expected to follow the Contact Precautions and Contact Precautions Enhanced protocols to perform handwashing with soap and water prior to entering and exiting the patient's rooms, don gown and gloves prior to entering the room, and performing handwashing prior to exiting the patient's rooms as per the "Contact" and "Droplet" Precaution protocols. S2 confirmed Patient #2 and Random Patient #5 (R5) both had signs posted on their doors labeled, "Contact Precautions Enhanced". The Interim Director of Nursing,S2 further indicated the Isolation Precautions policies do not include the posting of the signs labeled, "Contact Precautions Enhanced" on Patient #2's (Room "a"'s) and/or Random Patient #5's (R5's) doors.

Review of the policy titled, "Guidelines for Isolation of Specific Conditions & (and) Diseases", Policy Number: III.B.7.0, Approval Date of 08/11/11, Effective Date of 04/2011, Reviewed and Revised date of 04/2011, read, "Special Transmission-Based Precautions are identified for patients known or suspected to be infected with highly transmissible organisms. Knowing which specific isolation precautions to utilize for a particular disease or condition is a key strategy for the prevention of Healthcare Acquired Infections (HAI). It is policy to assure that patients requiring isolation precaution are treated appropriately, hospital personnel adhere to the strategies recommended by the Centers for Disease Control (CDC). The following table is to be utilized when deciding which type and duration of isolation to apply to a patient with a particular disease or condition. Procedure: Abbreviations for Types of Precautions: C, Contact; D, Droplet...Duration of precautions: DI: Duration of illness...Infection/Condition...Bacterial not listed elsewhere (including Gram negative bacterial) MRSA pneumonia...Type D,C...Duration DI...Infection/Condition...Multi-Drug Resistant (MRSA)...Type C...Duration...DI...".

The policy titled, "Guidelines for Transmission Based Precautions", Policy Number III.B.6.0, Approval date of 08/11/11, Effective Date of 09/2009, Revised date of 04/2011, and Reviewed date of 08/2009, read, "Policy to reduce the risk of transmission of microorganism, Contact, Droplet Precautions will be routinely practiced by all hospital personnel whenever indicated. The following strategies, as recommended by the Centers for Disease Control (CDC) must be adhered to in order to protect patients and personnel. A: Contact Precautions: Use Contact Precautions for patients with known or suspected infections or evidence of syndromes that represent an increased risk for contact transmission-See policy III.D.4.27.2 "Guidelines for Isolation of Specific Conditions/Diseases". 1. Place patients on Contact Precautions in a single-patient room when available. Use of Personal Protective Equipment (PPE) 1. Gloves: Wear gloves whenever touching patient's intact skin or surfaces and articles in close proximity to the patient (e.g., medical equipment, bed rails). Don gloves upon entry into the room. 2. Gowns: Wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. Don gown upon entry into the room. 3. Removal of PPE: Remove gloves then gown and observe hand hygiene before leaving the patient-care environment. After removal, ensure that clothing and skin do not contact potentially contaminated surfaces that could result in possible transfer of microorganism to other patients or environmental surfaces. B. Droplet Precautions: Use Droplet Precautions for patients known or suspected to be infected with pathogens transmitted by respiratory droplets (e.g., large-particle droplets greater than 5 micron in size) that are generated by a patient who is coughing, sneezing, or talking (see policy III.D.4.27.2 "Guideline for Isolation of Specific Conditions/Diseases"). 1. Place patients in a single-patient room when available. Use of Personnel Protective Equipment (PPE) 1. Don a mask upon entry into the patient room. 2. No recommendation for routinely wearing eye protection (e.g., goggle or face shield), in addition to a mask, for close contact with patients who require Droplet Precautions".

Review of the hospital's "Droplet Precautions" sign reflected "Visitors must go to nursing station BEFORE entering room.. . . Wash handsor use hand sanitizerupon entering and before leaving; Put on N95mask before entering room Visitors: see nurse for instructions"

25059

Based on record reviews, and interviews, the Infection Control Practitioner Officer, S3ICP failed to have a system in place for identifying, reporting, investigating, and controlling infections and communicable diseases of patients from January through August of 2012 as evidenced by:

1) failing to have accurate documented evidence to identify whether the patient's infections were healthcare-associated infections (HAIs) and/or community acquired infections (CAIs) recorded on the "Infection Control Surveillance Sheets"(tool used by the facility to capture data relating to Infection Control) for patients identified with having an infection for the following months:

January, 2012 -3 of 5 patients (R49, R51, R53)
February, 2012 -6 of 11 patients (R42, R44, R45, R46, R49, R50)
March, 2012 -6 of 13 patients (#3, R37, R38, R43, R47, R48)
April, 2012 -3 of 7 patients (R35, R36, R37)
May, 2012- 6 of 13 patients (#2, R8, R9, R32, R33, R34)
June, 2012- 5 of 13 patients (#2, R4, R11, R30, R31).
July, 2012 -9 of 20 patients (R3, R4, R10, R12, R16, R28, R27, R29, R31)
August, 2012 - 7 of 18 patients (#2, #4, R3, R5, R6, R7 and R15).

2) failing to have documented evidence to accurately identify patient's with organisms on admission for:

January, 2012 - 3 of 5 patients (R41, R53, R54)
February, 2012 - 4 of 11 patients (R44, R45, R46, R52)
March, 2012 - 1 of 7 patients (R40)
April, 2012 - 1 of 7 patients (R33)
August, 2012, - 3 of 18 patients (#2, #4 and R16)

3) failing to have documented evidence of labs and/or cultures collected with no results for:

January, 2012 - 1 of 5 patients (R49)
April, 2012 - 1 of 7 patients (R36)
August, 2012 5 of 18 patients (#2, #4, R5, R6, R7)

Findings:
Review of the "Infection Control Surveillance Sheet Organisms on ADM (admission)" sheets (tool used by hospital to record data for Infection Control) from January 2012 - August 2012 revealed the following number of Infection Control Surveillance Sheets:
11 for January 2012
20 for February 2012
21 for March 2012
21 for April 2012
26 for May 2012
15 for June 2012
16 for July 2012
29 patient for August,
Patient #2:
Review of the Infection Control Surveillance sheet date of admission was on 05/14/12 and date of discharge on 06/22/12. There was a tissue culture positive with an organism on 05/30/12- 16 days after admission with no documented evidence of whether the organism was HAI and/or CAI for the month of May 2012-this section on the sheet was left blank. There were also a blood culture positive with an organism on 06/03/12- 19 days after admission with no documentation of whether the organism was HAI and/or CAI for the month of June 2012-this section on the sheet was left blank as of 08/24/12.
Further record review revealed the patient (#2) was re-admitted on 08/08/12 with no discharge date recorded on the Infection Control Surveillance sheet. There were 2 blood cultures collected from #2's (peripherally inserted central catheter) PICC line on 08/11/12- 3 days after admission. There was no documented evidence of the results of the 2 blood cultures recorded on the form as of 08/24/12-these sections were left blank on the sheet. Patient #3:
Review of Patient #3's Infection Control Surveillance sheet revealed date of admission was on 02/27/12 and date of discharge was on 03/30/12. There was a positive tissue culture on 03/12/12- 14 days after admission recorded as CAI for March 2012. There was no documented evidence Patient #3's organism was HAI for March 2012 as of 08/24/12.
Patient #4:
Patient (#4) was admitted on 08/02/12 with no date of discharge recorded on the Infection Control Surveillance sheet -this section was left blank. Review of the laboratory results dated/timed 08/02/12 at 11:50 p.m. same day of admission revealed a positive sputum culture. There was no documented evidence of the positive sputum culture recorded on the Infection Control Surveillance sheet for August 2012. There was a culture collected from Patient #4's peripherally inserted central catheter (PICC) catheter tip on 08/13/12- 11 days after admission with no documentation of what the culture result was as of 08/24/12-this section was left blank on the sheet. There was no documented evidence recorded whether the positve culture results were HAI and/or CAI recorded for August 2012 as of 08/24/12.
Patient R3:
Review of the Infection Control Surveillance sheet revealed admission was 07/27/12 with no discharge date recorded-this section was left blank, it also revealed bacteria in the blood on date of admission. A tissue culture with yeast was recorded on 07/30/12- 3 days after admission. There was no documentation of whether the yeast infection culture on 07/30/12 was HAI and/or CAI for July 2012-this section on the sheet was left blank. Further review revealed there was a blood culture positive with anorganism on 08/11/12 at 9:02 am- 15 days from the day of admission on 07/27/12 with no documented evidence of whether the organism was HAI and/or CAI for August 2012- this was left blank on the form.
Patient R4:
R4 was admitted on 06/26/12 and discharged on 08/03/12 with organism on admission. Review of the Infection Control Surveillance sheet revealed there was a positive urine culture collected/resulted on 06/27/12- 1 day after admission. There was no documentation of whether the positive urine culture was HAI and/or CAI for June 2012-this section was left blank on the sheet. Further review revealed there was a positive sputum culture collected/resulted on 07/01/12- 6 days after admission and on 07/20/12- 24 days after admission with no documented evidence of whether the pseudomonas species on 07/01/12 and/or 07/20/12 were HAI and/or CAI for July 2012-these sections were left blank on the sheet.
Patient R5:
Patient R5 was admitted on 07/28/12 with no discharge date recorded on the Infection Control Surveillance sheet Further review revealed R5 had several organisms on admission: A blood culture collected on 08/03/12- 6 days after admission with no documented evidence of what the results were and/or whether it was HAI and/or CAI for August 2012- these sections were left blank on the sheet as of 08/24/12. There was a positive urine culture collected/resulted on 08/09/12- 12 days after admission with no documentation of whether the urine culture was HAI and/or CAI for August 2012-this section was left blank on the sheet. There was a PICC culture collected on 08/12/12-14 days after admission with no documented evidence of what the culture result was and/or whether the PICC culture was HAI and/or CAI for August 2012-these were left blank on the sheet. There were 2 blood cultures collected on 08/13/12-15 days after admission with no documented evidence of what the results were and/or whether blood cultures were HAI and/or CAI for August 2012-these sections were left blank on the sheet as of 08/24/12.
Patient R6:
Review of R6's Infection Control Surveillance sheet revealed an admission date on 07/31/12 with no discharge date recorded on the sheet-this section was blank. There were no organisms documented on admission-this section was left blank on the sheet. There were 2 blood cultures collected on 08/10/12-10 days after admission with no results recorded and/or whether the blood cultures were HAI and/or CAI for August 2012-this section was left blank on the sheet as of 08/24/12.
Patient R7:
Review of Patient R7's Infection Control Surveillance sheet revealed a date of admit on 08/01/12 with no discharge date recorded -this section was left blank on the sheet. Further review revealed there was a urine culture collected on 08/05/12- 4 days after admission with no result recorded and/or whether the urine culture was HAI and/or CAI for August 2012-these sections on the sheet were left blank.
Patient R8:
Review of R8's Infection Control Surveillance sheet revealed an admission date on 04/24/12 and discharge date on 06/13/12. There were several organisms noted on admission. There was a positive abscess culture on 05/16/12-22 days after admission with no documented evidence of whether the culture was HAI and/or CAI for the May 2012-this section was left blank on the sheet. Further review revealed there was no documented evidence R8 had this specific organism on admission.
Patient R9:
Review of R9's Infection Control Surveillance sheet revealed an admit date of 05/02/12 and discharged on 06/08/12. Review of the sheet also revealed R9 was admitted with no organisms recorded on the sheet-this section was blank. There was a positive abscess culture on 05/07/12-5 days after admission identified by S3ICP,as a community acquired infection for May 2012. There was no documented evidence R9 had this organisms prior to admission. There was no documentation R9's organisms were identified as a HAI for May 2012.
Patient R10:
Review of the Infection Control Surveillance sheet revealed R10 was admitted on 07/26/12 with no discharge date documented -this was left blank. Further review revealed R10 had no organisms on admission. There was a positive urine culture collected/resulted on 07/26/12-same day of admission There was no documented evidence R10 was admitted with this organism-this section was left blank on the sheet. There was no documentation the urine culture organism was HAI and/or CAI for July 2012-this section was left blank. Further review revealed there was a tissue and bone cultures positive with organisms on 07/30/12 at 10:00 a.m. -4 days after admission with no documentation of whether the cultures were HAI and/or CAI for July 2012-this sections were left blank on the sheet.
Patient R11:
R11's Infection Control Surveillance sheet revealed an admission date on 06/01/12 and a discharge date on 06/15/12. Further review revealed R11 had 2 organisms on admission: organism of the wound and organism in the urine. There was a positive tissue culture on 06/04/12- 3 days after admission identified as a community acquired infection for June 2012 as of 08/24/12. Further review revealed there was no documentation R11's organism was HAI for June 2012.
Patient R12:
Review of Infection Control Surveillance sheet revealed R12 was admitted on 06/27/12 and discharged on 07/31/12 with no organisms documented on admission-this section was left blank on the sheet. There was a right, anterior, foot culture collected/resulted positive with 2 organisms on 07/02/12- 5 days after admission recorded as community acquired infections for July 2012.
Patient R15:
Review of Infection Control Surveillance sheet for R15's revealed admission was on 08/14/12 with no discharge date recorded on the form-this section was blank. R15 was admitted with 1organism. Further review revealed there was a positive sputum culture on 08/20/12-6 days after admission with no documented evidence of whether it was HAI and/or CAI for August 2012-this section was left blank on the sheet.
Patient R16:
Review of the Infection Control Surveillance sheet revealed R16 was admitted on 07/18/12 and discharged on 08/07/12. R16 had no organisms on admission recorded on the form-this section was blank. Further review revealed there was a lumbar puncture positive with West Nile virus on 07/13/12-5 days prior to admission. There was no documentation R16 had west nile virus identified as an organism on admission-as this section was blank.
Patient R27:
R27's Infection Control Surveillance sheet revealed the patient was admitted on 06/25/12 and discharged on 07/30/12. Further review revealed R27 had no organisms on admission-this section was left blank on the sheet. There was a positive left hip culture collected/resulted on 07/02/12-7 days after admission identified as CAI for July 2012. The
Patient R28:
Review of R28 Infection Control Surveillance sheet was admitted on 05/29/12 and discharged on 07/25/12. Further review revealed R28 had 2 organisms on admission: There was a positive blood culture collected/resulted on 07/09/12- 14 days after admission with no documented evidence of whether the culture was HAI and/or CAI for July 2012 Further review revealed there was a positive PICC culture on 07/10/12-15 days after discharge with no documentation of whether the organism was HAI and/or CAI for July 2012 as of 08/24/12.
Patient R29:
Review of the Infection Control Surveillance sheet revealed R29's admission date was 06/28/12 and discharge date was 07/27/12. Further review revealed R29 had 2 organisms on admission: There was a positive tissue, culture on 07/02/12- 4 days after admission identified as CAI for July 2012.
Patient R30:
The patient's Infection Control Surveillance sheet revealed (R30) was admitted on 05/25/12 and discharged on 07/03/12. R30 had gangrene recorded as the organism on admission. Further review revealed there was a positive right, foot, tissue collected/resulted 06/04/12-10 days after admission with no documented evidence of whether the foot culture was HAI and/or CAI for June 2012.
Patient R31:
R31 was admitted on 06/27/12 and discharged on 07/20/12. Review of the Infection Control Surveillance sheet revealed R31 had an organism in the blood on admission. There was a positive sacrum culture collected/resulted on 07/02/12-5 days after admission with no documentation of whether the sacrum culture was HAI and/or CAI for July 2012.
Patient R32:
Review of the Infection Control Surveillance sheet revealed R32 admission date was on 05/02/12 and discharge date was on 05/17/12. There was a positive sputum, culture on 05/04/12- 2 days after admission with no documented evidence of whether the organism was HAI and/or CAI for May 2012.
Patient R33:
Review of R33 Infection Control Surveillance sheet was admitted on 04/24/12 and discharged on 05/24/12. Further review revealed R33 had no organisms on admission-this section was blank on the sheet. There was a positive right, thigh, abscess, culture collected/resulted on 05/02/12- 8 days after admission. Further review revealed there was no documentation of whether the organism was HAI and/or CAI for May 2012.
Patient R34:
Review of the Infection Control Surveillance sheet revealed R34's admission date was on 05/01/12 and discharge date was on 05/21/12. Further review revealed R34 had 1organism on admission. There was a positive abscess culture collected/resulted on 05/07/12- 6 days after admission with no documented evidence of whether the culture was HAI and/or CAI for the month of May, 2012.
Patient R35:
Review of R35 Infection Control Surveillance sheet revealed R35 was admitted on 04/12/12 and discharged on 05/16/12. Further review revealed there was a positive urine culture collected/resulted on 04/12/12-same day of admission with no documentation of whether the organism was HAI and/or CAI for April 2012- this section was left blank on the sheet.
Patient R36:
Review of the Infection Control Surveillance sheet revealed R36's admission date was 04/13/12 and discharge date was 05/10/12. R36 had no organisms on admission-this section was left blank on the sheet. Further review revealed there was a positive right, foot, culture collected on 04/17/12-4 days after admission with no record of what the culture result was for April 2012-this section was blank on the sheet. There was no documented evidence of whether the positive right, foot, culture collected on 04/17/12 was HAI and/or CAI for April 2012-this section was left blank on the sheet.
Patient R37:
Revie of R37 Infection Control Surveillance sheet R37 was admitted on 03/10/12 and discharged on 04/18/12. Further review revealed R37 had no organisms on admission-this section was blank on the sheet. There was a positive sputum culture collected/resulted on 03/26/12-16 days after admission with no documented evidence of whether the culture was HAI and/or CAI for March 2012-this section was left blank on the sheet. Further review revealed there was a positive stool culture on 03/27/12- 17 days after admission recorded as HAI for March 2012. There were two (2) other stool cultures collected/resulted on 03/31/12 and on 04/05/12 with no documented evidence of whether the stool cultures were HAI and/or CAI for March and/or April 2012-these sections on the sheet were left blank as of 08/24/12.
Patient R38:
Review of Infection Control Surveillance sheet revealed R38's date of admission was on 03/16/12 and date of discharge was on 04/23/12. R38 had no organisms on admission-this section was left blank on the sheet. Further review revealed there was a positive abdominal, abscess, culture collected/resulted on 03/19/12- 3 days after admission with no documentation of whether the culture was HAI and/or CAI for March 2012-this section was left blank.
Patient R40:
Review of R40's Infection Control Surveillance sheet revealed admission date was 03/14/12 and discharge date was 04/13/12. R40 had no organisms on admission-this section was blank on the sheet. Further review revealed a positive urine culture collected/resulted on 03/15/12- 1 day after admission. There was no documentation R40 was admitted with organism on admission as of 08/24/12.
Patient R41:
Review of the Infection Control Surveillance sheet revealed R41 was admitted on 01/28/12 and discharged on 03/08/12. R41 had no organisms on admission-this section was left blank on the sheet. Further review revealed there was a positive urine culture on 01/30/12- 2 days after admission. There was no documented evidence R41 had the organism on admission-this section was blank.
Patient R42:
Review of R42's Infection Control Surveillance sheet revealed the admission date of 02/08/12 and discharge date on 03/17/12. R42 had no organisms on admission-this section was left blank on the sheet. Further review revealed there was a positive urine culture on 02/27/12- 19 days after admission identified as a CAI for February 2012. There was a positive PICC blood culture collected/resulted on 02/28/12- 20 days after admission identified as a CAI for February 2012.
Patient R43:
Review of the Infection Control Surveillance sheet revealed R43's was admitted on 03/05/12 and discharged on 03/28/12. R43 had no organisms on admission-this section was left blank on the sheet as of 08/24/12. Further review revealed there was a positive wound culture collected/resulted on 03/14/12- 9 days after admission identified as a CAI for March 2012.
Patient R44:
R44's Infection Control Surveillance sheet revealed an admission date on 02/22/12 and a discharge date on 03/22/12. R44 had 1organisms on admission: Further review revealed there was a positive urine culture on 02/22/12-same day of admission. Further review revealed there was no documented evidence the organism was identified as a HAI and/or CAI for February 2012-this section was left blank on the sheet.
Patient R45:
Review of the Infection Control Surveillance sheet for R45 revealed an admission date on 02/13/12 and discharge date on 03/05/12. R45 had 1 organisms on admission: Further review revealed there was a positive urine culture on 02/14/12- 1 day after admission with no documentation R45 had the organism on admission and/or whether the culture was HAI and/or CAI for February 2012.
Patient R46:
Review of R46 Infection Control Surveillance sheet revealed an admit date of 02/06/12 and discharged on 03/06/12. R46 had 1 organism on admission. Further review revealed there was a positive sputum culture on 02/08/12- 2 days after admission. There was no documented evidence R46 had the organism on admission and/or whether the organism was HAI and/or CAI for February 2012. Further review revealed there was a positive sputum culture02/12/12- 6 days after admission identified as a CAI for February 2012. There was a positive sputum culture on 02/22/12-16 days after admission with no documented evidence of whether the culture was HAI and/or CAI for February 2012.
Patient R47:
Review of the Infection Control Surveillance sheet revealed R47 was admitted on 03/08/12 and discharged was 03/28/12. R47 had no organisms on admission-this section was left blank on the sheet. Further review revealed there was a positive urine, culture on 03/17/12- 9 days after admission identified as a CAI for March 2012.
Patient R48:
Review of R48's Infection Control Surveillance sheet revealed admission date was on 03/05/12 and discharge date was on 03/12/12. R48 had 2 organisms on admission: Further review revealed there was a positive sputum culture on 03/06/12- 1 day after admission. There was no documentation R48 was admitted with the organism on admission and/or whether the culture was HAI and/or CAI for March 2012. Further review revealed R48 expired on 03/14/12.
Patient R49:
Review of the Infection Control Surveillance sheet revealed R49 was admitted on 01/16/12 and discharged on 02/17/12. R49 had 1organism on admission. Further review revealed there was a positive sputum culture on 01/24/12- 8 days after admission with no documented evidence of whether the culture was HAI and/or CAI for January 2012-this section was left blank on the sheet. There was a wound culture collected on 01/27/12- 11 days after admission with no documentation the results. Further review revealed there was no documented evidence of whether the wound culture for R49 collected on 01/27/12 was HAI and/or CAI for January 2012-this section was left blank on the sheet. There was a positive sputum culture on 02/13/12- 28 days after admission identified as a CAI for February 2012.
Patient R50:
R50's Infection Control Surveillance sheet revealed an admission date on 02/08/12 and a discharge date on 02/20/12. Further review revealed there was a positive heel, wound culture on 02/14/12- 6 days after admission with no documented evidence of whether the culture was HAI and/or CAI for February 2012-this section was left blank on the sheet.
Patient R51:
Review of R51's Infection Control Surveillance sheet with a date of admission of 01/03/12 and date of discharge was on 02/02/12. R51 had no organisms on admission-this section was left blank on the sheet. Further review revealed there was a positive toe culture on 01/06/12- 3 days after admission identified as a CAI for January 2012.
Patient R52:
Review of Infection Control Surveillance sheet with a date of admission on 02/07/12 and date of discharge on 02/20/12 revealed R52 had no organisms on admission-this section was left blank on the sheet. There was a positive urine culture on 02/08/12- 1 day after admission. Further review revealed there was no documentation R52 was admitted with a positive urine on admission-this section was left blank There was a positive heel wound on 02/08/12- 1 day after admission with no documented evidence the patient was admitted with the organism as of 08/24/12. The section titled, "organisms on admission" for R52 was left blank on the sheet.
Patient R53:
Review of R53's Infection Control Surveillance sheet revealed admission date was 01/27/12 and discharge date was on 02/23/12. R53 had no organisms on admission-this section was left blank on the sheet as of 08/24/12. Further review revealed there was a positive foot culture on 01/28/12- 1 day after admission with no documented evidence the patient was admitted with the organism-this section was left blank on the sheet. There was no documentation of whether the organism was HAI and/or CAI for January 2012-this section was left blank on the sheet.
Patient R54:
Review of the Infection Control Surveillance sheet revealed R54 was admitted on 01/30/12 and discharged on 02/23/12. R54 had no organisms on admission-this section was left blank on the sheet.
During an interview on 08/23/12 at approximately 1:50 p.m. S3ICP indicated she has not tracked and/or trended patient's infections since her date of hire in November of 2011. S3ICP further indicated she does not have an infection control log or sytem in place to track and trend all patient and/or employee infections. S3ICP stated she had Infection Control Surveillance sheet for all patients from the date of admission through discharge.
In another interview on 08/24/12 at 9:40 a.m., S3ICP, confirmed there was no documented evidence on the patient's (R3's, R4's, R5's, R6's, R7's, R8's, R9's, R10's, R11's, R12's, R13's, R14's, R15's, R16's, R17's, R18's, R19's, R21's, R24's, R25's, R26's, R27's, R28's, R29's, R31's) Infection Control Surveillance sheet of tracking, trending, or identifying to determine whether each patient's organisms were HAI and/or CAI handwritten on the sheets for the months of July and August of 2012. S3ICP verified R3 and R5 had healthcare associated infections not recorded on the August of 2012 Infection Control Surveillance sheet. S3ICP, indicated a patient admitted with an infection, a wound and signs and symptoms of an infection (fever, drainage) are not healthcare associated infections (HAI); they are community acquired infections (CAI). S3ICP further indicated there is no timeframe regarding the day the patient was admitted verses the day a culture was collected even 3 to 15 days after the patient has been admitted into the hospital. A patient admitted with an infection and a history of an infection automatically has community acquired infections not healthcare associated infections.