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Based on record review and interview, the hospital failed to meet the Condition of Participation for Food and Dietetic Services as evidenced by:

1) Failing to ensure Dietetic Services were currently under the direction of a qualified manager. The hospital failed to employ a qualified, full time Dietary Manager to serve as Director of Food and Dietetic Services. (See Findings under A-0620)

2) Failing to ensure a qualified Dietitian was available to supervise the nutritional aspects of patient care. The hospital failed to employ a qualified Dietician on a full time, part-time, or on a consulting basis. (See Findings under A-0621)

3) Failing to ensure individual patient needs were met in accordance with recognized dietary practices and in accordance with orders of the practitioner responsible for the care of the patient by failing to provide therapeutic diets as prescribed for 1 (#3) of 6 (#1-#6) sampled patients reviewed and by failing to assess and monitor the nutritional status for 5 ( #2,#3,#4,#5,#6) of 5 (#2,#3,#4,#5,#6) current sampled patients reviewed.. (See Findings under A-0629)

Based on observation, interview and record review, the hospital failed to meet the Condition of Participation for Infection Control as evidenced by:

1) Failing to ensure the person designated as Infection Control Officer was qualified through education, training and/or certification as evidenced by appointing a nurse (S11InfectionControl) to the position of Infection Control Officer who lacked specialized education, training, and/or certification in Infection Prevention and Control. (See findings under A-0748).

2) Failing to ensure the effective implementation of policies/procedures relative to infection control to include a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. This was evidenced by the hospital's failure to identify/track/trend the potential pattern/source of Hospital Acquired Infections to mitigate risks contributing to the potential spread of infections from June of 2014 to present (October of 2014) and failure to maintain a sanitary physical environment by allowing the disposal of laundry water (contaminated with potentially infectious waste from wounds) from the hospital's washing machine onto the grounds of the hospital and the city sidewalk/street. (See findings under A-0749).

Based on interview and record review, the registered nurse (RN) failed to ensure the supervision and salutation of nursing care provided to each patient as evidenced by entering admission orders in the medical record without first obtaining authorization from the prescribing and/or admitting practitioner. This was identified for 1 (#3) of 6 (1-6) patients sampled. Findings:

Review of the medical record for Patient #3 revealed she had been admitted to the hospital on 9/10/14 at 17:30 (5:30) p.m. with diagnoses which included the following, in part: Osteomyelitis, NHW (non-healing wound) sacrum. Patient #3 was listed as a current patient on the 10/7/14 census.
Review of Patient #3 ' s medical record revealed orders for the following medications, dated 9/10/14, 1505 (3:05 pm):
Alprazolam0.5 mg ( milligram) tablet- take 1 tablet po (by mouth) q (every) 8 hours PRN (as needed)
Diphenhydramine 25 mg capsule- take 1 capsule po q 6 hours PRN
Zofran 4mg/2ml (milliliters) injection IV (intravenous) q 8 hours PRN
Oxycodone-Acetaminophen 7.5 mg/325mg per tablet- take 1 tablet po q 4 hours PRN pain
Meropenem 1 gram IVPB ( IV piggy back) q 8 hours- ends 10/19/14
Zolpidem 5mg tablet- take 1 tablet po q hs PRN sleep
Acetaminophen 325mg tablet- take 2 tablets (650mg) po q 4 hours PRN pain.
Diclofenac 25 mg EC tablet-take 25 mg po TID (3 times/day)
Diphenoxylate- atropine 2.5/0.025 mg per tablet- take 1 tablet po QID ( 4 times/day) PRN
Fluoxetine 10mg tablet- take 10mg po q day
Furosemide 40mg tablet - take 40 mg po BID (2 times/day)
Medroxyprogesterone 150mg/ml injection- inject 150 mg into the muscle q 3 months
Solifenacin 5mg tablet - take 5 mg po q day.
The Medication orders had been signed by S13RN on 9/10/14 at 17:35 p.m.as RBTO (read back telephone order) with MD ' s name/S13RN.

Review of Patient #3 ' s Routine Admission Orders, dated 9/10/14 at 5:30 p.m. revealed the following Admit Diagnoses: Osteomyelitis, NHW (non-healing wound) sacrum. The diet selected was Cardiac, Low Cholesterol, and NAS (no added salt).
Under a section titled Labs: the following orders were checked off: UA (urinalysis) with C&S - (Culture and Sensitivity)-if indicated, CMP (complete metabolic profile), CBC (complete blood count) within 24 hours of admission, then weekly.
Further review revealed the following orders were also checked off: Suprapubic catheter; NWB (Non- Weight Bearing); PICC line(percutaneous intravenous central catheter)- dressing changes q (every) 7 days and as needed- flush with 10 ml (milliliters) NS (normal saline) q 8 hours; and Wound Care Assessment.
The admission orders had been signed by S13RN on 9/10/14 at 17:35 p.m.as RBTO (read back telephone order) with MD ' s name/S13RN. Further review revealed the MD had not cosigned the order until 9/12/14 (unable to decipher time of signature).

In an interview on 10/8/14 at 3:30 p.m. with S13RN, she explained she had transcribed the Admission and Medication orders based upon Patient #3 ' s information from the transferring facility, not from orders from the physician. She said on admission the medications were usually obtained from a medication list from the previous facility. S13RN confirmed she had completed the Admit orders, including ordering labs and medications, without calling the MD even though she had signed the orders as RBTO (which indicates orders received directly from the MD per telephone). Upon further questioning, she explained she had been told, by other staff members, to complete the Admit Order sheet and Medication Order sheet and to sign it as telephone order read back and verified. She also confirmed the admitting MD had not signed the orders until 9/12/14.

In an interview on 10/8/14 at 3:40 p.m. with S2DON, she confirmed S13RN should have called the admitting Physician and obtained Admission and Medication orders for Patient #3. She verified transcribing orders from the transferring facility and signing them RBTO without consulting the physician was not an appropriate practice. S2DON also agreed ordering patient labs, diets and medications based upon information from the transferring hospital, without an MD order, was out of the scope of practice for a Registered Nurse.

Based on record review and interview, the hospital failed to ensure Dietetic Services were currently under the direction of a qualified manager by failing to employ a qualified, full time Dietary Manager to serve as Director of Food and Dietetic Services. Findings:

Review of facility records revealed no evidence to indicate dietetic services were currently under the direction of a qualified manager.

In an interview on 10/7/14 at 3:20 p.m., S1Administrator indicated that the hospital did not currently have a Dietary Manager. S1Administrator said the previous Dietary Manager, S6Dietary, had to leave for health reasons and the hospital has not hired a new Dietary Manager. S1Administrator stated," I need to start looking to hire a new Dietary Manager".

In an interview on 10/7/14 at 3:40 p.m., S6Dietary confirmed she was no longer the Dietary Manager for the hospital. S6Dietary reported she had returned to the hospital briefly in late August/early September 2014, but had to leave again for health reasons.

In an interview on 10/8/14 at 11:47 a.m., S9Dietician (former contracted Dietician) reported the last time she had provided Dietician services for the hospital was in June of 2014. S9Dietician reported there was no Dietary Manager at the hospital in June of 2014 when she last provided Dietician services at the hospital.

Based on record review and interview, the hospital failed to ensure a qualified Dietitian was available to supervise the nutritional aspects of patient care. The hospital failed to employ a qualified Dietician on a full time, part-time, or on a consulting basis. Findings:

Review of the facility's contracts revealed the facility had no current contract for the services of a qualified Dietician.

Review of documentation provided by S14ContractedNutritionalServices revealed the last visit by S9Dietician (former contracted Dietician) was on 6/29/14.

In an interview on 10/7/14 at 10:30 a.m., S1Administrator verified that the hospital had no current full-time, part-time, consulting or contracted Dietician.

In an interview on 10/8/14 at 10:41 a.m., S14ContractedNutritionalServices reported she had provided contracted Dietician services in the past but has not been onsite at the hospital since June of 2014. S14ContractedNutritionalServices explained she had not been paid for her services in months and she had considered this a breach of contract.

In an interview on 10/8/14 at 11:47 a.m., S9Dietician (former contracted Dietician) reported the last time she had provided Dietician services for the hospital was in June of 2014.

Based on record review and interview, the hospital failed to ensure patient nutritional needs were met in accordance with recognized dietary practices and in accordance with orders of the practitioner responsible for the care of the patient by 1) failing to provide therapeutic diets as prescribed for 1 (#3) of 6 (#1-#6) sampled patients reviewed and 2) failing to assess and monitor the nutritional status for 5 ( #2,#3,#4,#5,#6) of 5 (#2,#3,#4,#5,#6) current sampled patients reviewed. Findings:

1) failing to provide therapeutic diets as prescribed for 1 (#3) of 6 (#1-#6) sampled patients reviewed.

Review of Patient #3's Routine Admission Orders, dated 9/10/14 at 5:30 p.m. revealed the following Admit Diagnoses: Osteomyelitis, NHW (non-healing wound) sacrum. The diet selected was Cardiac, Low Cholesterol, and NAS (no added salt).

Review of Patient #3's medical record revealed no nutritional assessment had been performed.

A tour of the hospital kitchen, on 10/8/14 at 9:05 a.m., revealed no evidence of a list of patients with special dietary needs. Patient #3's special dietary needs (Cardiac, Low Cholesterol, and NAS diet) were not identified/addressed in any way to alert the staff in the food preparation area of the hospital kitchen.

In an interview on 10/7/2014 at 2:30 p.m., S10Cook indicated that she cooked the same meal for everyone in the hospital. S10Cook indicated that she seasoned the food using Zataran's seasoning. S10Cook further indicated that she followed the menu plan from Conco services and was unaware of any current patients being on a specialized and/or therapeutic diet.

In an interview on 10/8/14 at 9:15 a.m., S12Cook indicated that she thought all of the current patients in the hospital were on a regular diet. S12Cook indicated that she was not aware of any current patients being on a specialized and/or therapeutic diet. S12Cook reported they usually had a list up in the kitchen of patients on special diets. S12Cook was asked if she prepared different meals from special menus which addressed special dietary needs of individual patients such as Diabetic, NCS (no concentrated sweets), and NAS (no added salt) and she replied," No, not really, we just prepare the same meal for everybody."


2) failing to assess and monitor the nutritional status for 5 ( #2,#3,#4,#5,#6) of 5 (#2,#3,#4,#5,#6) current sampled patients reviewed.

Review of the hospital' s contracts revealed the hospital had no current contract for the services of a qualified Dietician.

Review of documentation provided by S14ContractedNutritionalServices revealed the last visit by S9Dietician (former contracted Dietician) was on 6/29/14.

Patient #2
Review of Patient #2's Routine Admission Orders, dated 9/26/14 revealed the following Admit Diagnoses: Meningitis, and an open wound to her back. The diet selected was a regular diet. Further review revealed no nutritional assessment had been performed, by a dietician, on this patient. In addition, there was no documentation of ongoing monitoring of the patient's nutritional status by a dietician or by hospital staff.

Patient #3
Review of Patient #3's Routine Admission Orders, dated 9/10/14 at 5:30 p.m. revealed the following Admit Diagnoses: Osteomyelitis, NHW (non-healing wound) sacrum. The diet selected was Cardiac, Low Cholesterol, and NAS (no added salt). Further review revealed no nutritional assessment had been performed, by a dietician, on this patient. In addition, there was no documentation of ongoing monitoring of the patient's nutritional status by a dietician or by hospital staff.

Patient #4
Review of Patient #4's Routine Admission Orders, dated 10/2/14 revealed the following Admit Diagnoses: Sepsis, wound to sacrum and right foot. The diet selected was Jevity 1.5 bolus 240cc per G-Tube. Further review revealed no nutritional assessment had been performed, by a dietician, on this patient. In addition, there was no documentation of ongoing monitoring of the patient's nutritional status by a dietician or by hospital staff.

Patient #5
Review of Patient #5's Routine Admission Orders, dated 9/17/14 revealed the following Admit Diagnoses: Spinal/Rectal Abscess. The diet selected was regular. Further review revealed no nutritional assessment had been performed, by a dietician, on this patient. In addition, there was no documentation of ongoing monitoring of the patient's nutritional status by a dietician or by hospital staff.

Patient #6
Review of Patient #6's medical record revealed he was admitted on 10/1/14 with the following Admit Diagnoses: Osteomyelitis of the sacrum and UTI (urinary tract infection). The diet selected on the patient's admit orders was Regular. Further review revealed no nutritional assessment had been performed, by a dietician, on this patient. In addition, there was no documentation of ongoing monitoring of the patient's nutritional status by a dietician or by hospital staff.

In an interview on 10/7/14 at 10:30 a.m., S1Administrator reported that the hospital currently has no full-time, part-time, consulting or contracted Dietician.

In an interview on 10/8/14 at 10:41 a.m., S14ContractedNutritionalServices reported that she provided contracted Dietician services in the past but has not provided on-site services at the hospital since June of 2014 due to non-payment of services.

In an interview on 10/8/14 at 11:47 a.m., S9Dietician (former contracted Dietician) confirmed the last time she had provided Dietician services for the hospital was in June of 2014. S9Dietician confirmed she had not performed nutritional assessments or ongoing nutritional evaluations on any patients since June of 2014.

Based on observation and interview, the hospital failed to ensure that the physical plant and environment of care was maintained in a manner to ensure an acceptable level of safety and quality. Findings:

Observations of the facility's environment on 10/7/14 between 10:35 a.m. and 12:10 p.m. revealed the following:

*Outside of the building that housed the laundry there was an open pipe exiting through the wall where soapy water was flowing onto the ground draining from the building to the curb of the street, approximately 20-25 feet. There were 2 washing machines inside of the building with drain hoses connected to a pipe in the wall. There was a laundry sink that was not connected to a water supply or drain.
*Room (a) had a broken light fixture in the bathroom and water stained ceiling tile.
*Room (c) had an area of sheetrock next to the floor in the bathroom that was crumbling, corrosive lavatory faucets with rough sharp edges were noted in the bathroom.
*Room (d) had a sagging ceiling tile located in front of the window that was stained, damp, and had multiple black spots. The light in the ceiling did not function.
*Room (e) had a corrosive lavatory faucet with sharp edges in the bathroom.
*Room (f) had a corrosive lavatory faucet with sharp exposed edges and water stains to the ceiling tile in the bathroom.
*Room (g) had a black fuzzy substance around the molding of the air conditioner, the lower right corner of the window had a crack in the brick mortar, a damp to touch area of mortar below the window, and a corrosive lavatory faucet with sharp edges in the bathroom.
*Room (h) window had a missing glass pane, corrosive lavatory faucets with sharp edges.

Observation of the facility's environment on 10/8/14 at 9:05 a.m. revealed the following:
*Room (b) had dry water stains on the ceiling tile.

Interview on 10/7/14 at 11:15 a.m. with S4Maintenance and S3LPN confirmed that the ceiling tile was wet because there had been a leak in the roof. S3LPN with a spray bottle of diluted bleach sprayed the ceiling tile and the dark areas disappeared. S4 Maintenance stated that he was not aware of the facility being tested for mold.

In an interview on 10/7/2014 at 12:10 p.m., the physical plant findings were confirmed by S1 Administrator.

Interview on 10/8/14 at 9:35 a.m. with S3LPN confirmed the stains on the ceiling tile but stated that the room did not leak during the last rain storm a few days ago.

Interview on 10/8/2014 at 10:10 a.m. with S1Administrator revealed that she had been at the hospital for approximately 3 weeks. S1Administrator stated that she was aware of the waste water from the washing machines being dumped on the ground and the leak in Room (d).

Based on record review and interview, the hospital failed to ensure the person designated as Infection Control Officer was qualified through education, training and/or certification as evidenced by appointing a nurse (S11Infection Control) to the position of Infection Control Officer who lacked specialized education, training, and/or certification in Infection Prevention and Control. Findings:

Review of S11InfectionControl's personnel record revealed no evidence of education, training, and/or certification in Infection Prevention and Control.

In an interview on 10/9/14 at 10:30 a.m., S11InfectionControl reported that she had been the hospital's Infection Control Officer officially for 1-2 weeks. When asked about her (S11Infection Control) qualifications to be the Infection Control Officer of the hospital, S11InfectionControl indicated that she had no specialized education, training and/or certification in Infection Prevention and Control.

In an interview on 10/9/14 at 10:40 a.m., S2DON verified that S11InfectionControl had no specialized education, training and/or certification in Infection Prevention and Control.

In an interview on 10/9/14 at 10:42 a.m., S1Administrator verified that S11InfectionControl had no specialized education, training and/or certification in Infection Prevention and Control.

Based on record review and interview, the hospital failed to ensure the effective implementation of policies/procedures relative to infection control to include a system for identifying, reporting, investigating, prevention,and controlling infections and communicable diseases of patients and personnel. This was evidenced by the hospital's:
1) failure to investigate the potential pattern/source of Hospital Acquired Infections (HAIs) to mitigate risks contributing to the potential spread of infections from June of 2014 to present (October of 2014); and
2) failure to maintain a sanitary physical environment as evidenced by :
a. a small refrigerator labeled " Patient Food", located in dining area, containing unlabeled opened food items and partially thawed, unlabeled individual frozen dinners. The refrigerator had no thermometer inside the refrigerated compartment.
b) a housekeeping closet, containing "wet floor" signs and biohazard containers, with 2 brown and black tinged falling ceiling tiles that also contained holes.
c) a heating and cooling window unit in patient room FG with a hole in the accordian side curtain stuffed with a paper towel .
Findings:

1) Failing to identify/track/trend the potential pattern/source of Hospital Acquired Infections to mitigate risks contributing to the potential spread of infections from June of 2014 to present (October of 2014);

Review of the hospital's Monthly Infection Control documentation of Health Care Acquired Infections (acquired in facility) revealed the following:
6/2014:
Patient #R1:
Date of Admit: 5/6/14; Culture: 6/5/14; Site: Buttock; Result: 6/7/14: Organism: Proteus, Klebsiella (MDRO) Acinetobactor; Enterococcus
Culture: 6/18/14; Site: Buttock; Result: 6/20/14: Organism: Proteus, Klebsiella, Pseudomonas; Enterococcus

Patient #R2:
Date of Admit: 5/21/14; Culture: 6/14/14; Site: Sacrum; Result: 6/16/14: Organism: Proteus, Klebsiella
Culture: 6/22/14; Site: Sacrum; Result: 6/25/14: Organism: Serratia, Klebsiella, Pseudomonas; Enterococcus.

Patient #R3:
Date of Admit: 5/23/14; Culture: 6/14/14; Site: Right Groin; Result: 6/16/14: Organism: Staph (Staphylococcus)

7/2014:
Patient #R1:
Date of Admit: 5/6/14; Culture: 7/1/14; Site: Buttock; Result: blank: Organism: Proteus, Klebsiella - colonized

Patient #R2:
Date of Admit: 5/21/14; Culture: 7/2/14; Site: Sacrum; Result: 7/4/14; Organism: Acinetobactor #1&2, Pseudomonas
Culture: 7/21/14; Site: Sacrum; Result: 7/23/14; Organism: Acinetobactor

Patient #R4:
Date of Admit: 7/7/14; Culture: 7/22/14; Site: Urine; Result: 7/23/14: Organism: Yeast, Klebsiella

Patient #R5:
Date of Admit: 7/22/14; Culture: 7/26/14; Site: Sputum; Result: 7/23/14: Organism: Serratia, Pseudomonas
Culture: 7/28/14; Site: Trachea; Result: 7/28/14: Organism: Serratia, Pseudomonas

Patient #R6:
Date of Admit: 6/24/14
Culture: 7/2/14; Site: Sacrum; Result: 7/4/14; Organism: Acinetobactor, #1&2, Pseudomonas

Patient #R7:
Date of Admit: 6/27/14; Culture: 7/21/14; Site: Abdomen; Result: 7/21/14; Organism: Acinetobactor, Klebsiella, Proteus

Patient #R8:
Date of Admit: 7/14/14; Culture: 7/23/14; Site: R (Right) thigh; Result: 7/26/14; Organism: Acinetobactor, Klebsiella, Proteus

Patient #R9:
Date of Admit: 7/11/14; Culture: 7/15/14; Site: Sputum; Result: 7/18/14; Organism: Acinetobactor

8/2014:
Patient #R7:
Date of Admit: 6/27/14; Culture: 7/31/14; Site: Abdomen; Result: 8/3/14; Organism: Acinetobactor, Proteus, Enterococcus
Culture: 8/10/14; Site: Abdomen; Result: 8/12/14; Organism: Acinetobactor
Culture: 8/18/14; Site: Abdomen; Result: 8/20/14; Organism: Acinetobactor, Enterococcus

Patient #R8:
Date of Admit: 7/14/14; Culture: 8/1/14; Site: R (Right) thigh; Result: 8/3/14; Organism: Acinetobactor, Proteus

Patient #R10:
Date of Admit: 7/15/14; Culture: 8/15/14; Site: L ( left) hip; Result: 8/18/14; Organism: Acinetobactor, #1&2,
Culture: 8/25/14; Site: L (left) hip; Result: 8/28/14; Organism: Klebsiella

9/2014:
Patient #5:
Date of Admit: 9/17/14; Culture: 9/24/14; Site: Urine; Result: 9/24/14; Organism: Yeast

Patient #R11:
Date of Admit: 8/15/14; Culture: 9/4/14; Site: Sutures- Abdomen; Result: 9/8/14; Organism: Klebsiella

Patient #R12:
Date of Admit: 8/25/14; Culture: 9/17/14; Site: Sacrum; Result: 9/20/14; Organism: Enterococcus, Pseudomonas, E.(Escherichia) Coli

Patient #R13:
Date of Admit: 8/26/14; Culture: 9/10/14; Site: Sacrum; Result: 9/12/14; Organism: Acinetobactor

Review of the hospital's Quality Assurance/Performance Improvement Monitoring for the Infection Control Department revealed the following:
Healthcare Acquired Infection Rate:

6/2014:
Indicator: Acceptable Threshold: 0%; Compliance %: 27%; Total Number of Healthcare Acquired Infections: 4; Total Number of Infections:15; Recommendations: Continue Monitoring; Follow-up: 7/2014. Further review revealed no description of the type of monitoring or any type of assessments/interventions to evaluate potential spread pattern of infection from patient to patient within the hospital.

VRE (Vancomycin Resistant Enterococcus):
Indicator: Acceptable Threshold: blank; Compliance %: 0 %; Total Number of VRE Infections:0; Total Number of Infections:28; Recommendations: Continue Monitoring; Follow-up: 7/2014. Further review revealed no description of the type of monitoring or any type of assessments/interventions to evaluate potential spread pattern of infection from patient to patient within the hospital.

MRSA (Methicillin Resistant Staphylococcus Aureus):
Indicator: Acceptable Threshold: blank; Compliance %: 7 %; Total Number of MRSA Infections: 2; Total Number of Infections:28; Recommendations: Continue Monitoring; Follow-up: 7/2014. Further review revealed no description of the type of monitoring or any type of assessments/interventions to evaluate potential spread pattern of infection from patient to patient within the hospital.

7/2014:
Indicator: Acceptable Threshold: 0%; Compliance %: 40%; Total Number of Healthcare Acquired Infections: 8; Total Number of Infections:20; Recommendations: Continue Monitoring; Follow-up: 8/2014. Further review revealed no description of the type of monitoring or any type of assessments/interventions to evaluate potential spread pattern of infection from patient to patient within the hospital.

VRE (Vancomycin Resistant Enterococcus):
Indicator: Acceptable Threshold: blank; Compliance %: 0 %; Total Number of VRE Infections:0; Total Number of Infections:20; Recommendations: Continue Monitoring; Follow-up: 8/2014. Further review revealed no description of the type of monitoring or any type of assessments/interventions to evaluate potential spread pattern of infection from patient to patient within the hospital.

MRSA (Methicillin Resistant Staphylococcus Aureus):
Indicator: Acceptable Threshold: blank; Compliance %: 2 %; Total Number of MRSA Infections: 1; Total Number of Infections:20; Recommendations: Continue Monitoring; Follow-up: 8/2014. Further review revealed no description of the type of monitoring or any type of assessments/interventions to evaluate potential spread pattern of infection from patient to patient within the hospital.

8/2014:
Indicator: Acceptable Threshold: 0%; Compliance %: 27%; Total Number of Healthcare Acquired Infections: 3; Total Number of Infections:11; Recommendations: Continue Monitoring; Follow-up: 9/2014. Further review revealed no description of the type of monitoring or any type of assessments/interventions to evaluate potential spread pattern of infection from patient to patient within the hospital.

VRE (Vancomycin Resistant Enterococcus):
Indicator: Acceptable Threshold: blank; Compliance %: 9 %; Total Number of VRE Infections:1; Total Number of Infections:11; Recommendations: Continue Monitoring; Follow-up: 9/2014. Further review revealed no description of the type of monitoring or any type of assessments/interventions to evaluate potential spread pattern of infection from patient to patient within the hospital.

MRSA (Methicillin Resistant Staphylococcus Aureus):
Indicator: Acceptable Threshold: blank; Compliance %: 18%; Total Number of MRSA Infections: 2; Total Number of Infections:11; Recommendations: Continue Monitoring; Follow-up: 9/2014. Further review revealed no description of the type of monitoring or any type of assessments/interventions to evaluate potential spread pattern of infection from patient to patient within the hospital.

9/2014:
Indicator: Acceptable Threshold: 0%; Compliance %: 67%; Total Number of Healthcare Acquired Infections: 4; Total Number of Infections:6; Recommendations: Continue Monitoring; Follow-up: 10/2014. Further review revealed no description of the type of monitoring or any type of assessments/interventions to evaluate potential spread pattern of infection from patient to patient within the hospital.

VRE (Vancomycin Resistant Enterococcus):
Indicator: Acceptable Threshold: blank; Compliance %: 11 %; Total Number of VRE Infections:2; Total Number of Infections:19; Recommendations: Continue Monitoring; Follow-up: 10/2014. Further review revealed no description of the type of monitoring or any type of assessments/interventions to evaluate potential spread pattern of infection from patient to patient within the hospital.

MRSA (Methicillin Resistant Staphylococcus Aureus):
Indicator: Acceptable Threshold: blank; Compliance %: 0 %; Total Number of MRSA Infections: 0; Total Number of Infections:19; Recommendations: Continue; Follow-up: 10/2014. Further review revealed no description of the type of monitoring or any type of assessments/interventions to evaluate potential spread pattern of infection from patient to patient within the hospital.

The hospital's Quality Assurance/Performance Improvement Monitoring for the Infection Control Department for the month of 10/2014, had not been compiled as of the exit date of the survey (10/9/14).

Review of the Infection Control Policies and Procedures provided by the Hospital revealed no documented evidence of current policies/procedures related to surveillance/tracking/trending of infections for identification of potential pattern/source of spread of HAI from patient to patient.

In an interview on 10/9/14 at 10:30 a.m. with S11InfectionControl, she explained she had been Infection Control Officer officially for 1-2 weeks. She further explained the previous Infection Control Officer had been out on sick leave (at least one month prior to the survey). S11InfectionControl verified the Hospital had no current policies/procedures in place related to surveillance/tracking/trending of infections to identify the potential pattern/source of spread of HAI from patient to patient. She explained patients were admitted with many types of infections, due to the presence of wounds and the need for long-term IV ( intravenous) antibiotic treatment. S11InfectionControl said Acinetobactor seemed to be the bacteria that was the most common HAI present in this hospital and not as a potential transmittal of a community acquired bacteria patients had been admitted with. She said they had not investigated/identified the potential source of Acinetobactor yet, but she planned to. S11InfectionControl explained she planned to start identifying infections based upon type, source, and location using floor plans of the hospital to identify potential sources of spread, but she had not begun yet. She agreed the HAI ' s needed to be tracked to identify potential sources/patterns of spread in order to establish preventive measures and to identify potential staff education needs.

2) Failing to maintain a sanitary physical environment by allowing the disposal of laundry water (contaminated with potentially infectious waste from wounds) from the hospital's washing machine onto the grounds of the hospital and the city sidewalk/street.

Observations on 10/7/2014 between 10:35 a.m. and 12:10 p.m. revealed the following:

Outside of the building that housed the laundry there was an open pipe exiting through the wall where soapy water was flowing onto the ground draining from the building to the curb of the street, approximately 20-25 feet. There were 2 washing machines inside of the building with drain hoses connected to a pipe in the wall. The 2 washing machines were draining directly onto the grounds of the hospital and the city sidewalk/street through a pipe coming out of the wall.

Interview on 10/8/2014 at 10:10 a.m., S1Administrator reported that she has been at the hospital for approximately 3 weeks. S1Administrator stated that she was aware of the waste water from the washing machines being dumped on the grounds of the hospital.