HospitalInspections.org

Based on record review and interviews with hospital staff, the governing body does not ensure that services performed under a contract are provided in a safe and effective manner. Multiple contracted services/personnel are not evaluated by the QAPI program to assure the services are performed in a safe and effective manner by qualified personnel.

Findings:

1. Contract personnel respiratory, dietary, and agency nursing care are not evaluated by the hospital to ensure the contractor follows hospital policies, and are competent. There was no documentation the contracted personnel had been oriented, trained, and evaluated by the hospital.

2. These findings were reviewed at the exit conference. No further documentation was provided.

Based on review of hospital documents, surveyor observations and interviews with staff, the hospital failed to develop, and implement a grievance policy and process which included all required elements. The facility policy did not correctly identify a grievance. There was no evidence the facility trained staff on grievances. . This finding was reviewed and verified by administrative staff on 8/2/2012.

Based on review of policy, personnel files and interviews with staff the facility failed to train and supervise clinical staff responsible for sterilization of instruments. According to staff the facility sterilizes instruments to be used in wound debridements. There was no documentation as to the process used for cleaning, disinfecting, and sterilizing the instruments. The sterilizer log provided to surveyors did not indicate what was sterilized, the sterilization cycle used, and information from the sterilizer tapes. There was no documentation Staff I (identified as the clinician responsible for sterilization of instruments) had been trained, evaluated and deemed competent in sterilization practices. This finding was reviewed with administration at the time of the exit conference. No further documentation was provided.

Based on review of personnel files and meeting minutes and interviews with hospital staff, the hospital failed to designate/appoint an infection control professional with ongoing training on the principals and methods of infection control.

Findings:

1. Staff A told the surveyors on 08/02/2012 that Staff B was the infection control officer/preventionist.

2. Review of Staff B's personnel file only contain one document, 07/07-08/2005, concerning infection control training on the principals and methods of infection control. The surveyors questioned if Staff B had taken any other infection control training on principals and methods of infection control and implementing an effective infection prevention program. No further data was provided.

Based on review of infection control data, surveillance activities, and meeting minutes, and hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner (ICP) developed and maintained a comprehensive system for reporting, analyzing and controlling infections and communicable diseases among patients and staff and ensuring a sanitary environment.

Findings:

1. Meeting minutes containing infection control, did not reflect the program contained review and analysis with plans of action and follow-up of monitoring:
a. Meeting minutes documented nosocomial/hospital acquired infections occurred to patients in the hospital. The meeting minutes and documents provided did not demonstrate an analysis had occurred to identify if corrective actions, or policies and procedures or protocols revision need to occur or follow-up to ensure any corrective actions/revisions taken were effective.

b. The minutes contained a section labeled Employee Health; however,
i. Immunization history was not discussed. Review of personnel, staff, physicians an allied health, showed 5 of 5 staff and 12 of 12 physicians and allied health did not have complete immunization histories as required by Oklahoma State Hospital Licensure Standards and recommended by Centers for Disease Control (CDC) and its Advisory Committee on Immunization Practices (ACIP). Staff A stated the hospital did not get/review the health files for contract staff.
ii. Although the report/minutes continually stated no employee illness for the long term hospital, staff work and take care of patients in the other facility types within the organization and the building. The minutes contained documented illnesses for the other facilities within the building, but there was no review of the employee illness to ensure transmissions between staff and patients and/or staff and staff had not occurred.

d. The minutes contained a heading for Surveillance Report, but the only surveillance data documented was for known infections and whether any were nosocomial/hospital acquired infections. The minutes did not reflect analysis to determine if any policies and procedures needed revised to provide a safer environment for patient care.

d. The meeting minutes did not reflect the hospital has reviewed its disinfectants to ensure they were effective against the types of organism present at the hospital.

2. The program did not include monitoring/surveillance to ensure hospital infection control policies and procedures were followed. Other than the infection report, no other surveillance/monitoring was provided to the surveyors.
a. The hospital currently had a patient with clostridium difficile. The ICP had not monitored to ensure isolation precautions had been followed.
b. No hand hygiene monitoring was included in the program.
c. The hospital sterilizes instruments. The sterilizer/autoclave log only contain the date and the staff's name who ran the sterilizer. The log was not complete and did not specify what was sterilized, temperature or cycle times. The ICP has not monitored to ensure current sterilization practice guidelines were followed.
d. Monitoring of disinfect application has not been initiated to ensure manufacture's guidelines were followed.