Mid Coast Medical Center-Trinity

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 48749 Based on observation, document review, and interview the hospital failed to ensure: A. that the infection preventionist/infection control professional (Staff #9) was qualified through education, training, experience, or certification in infection prevention and control. Cross Refer to Tag A 0748 B. the hospital’s Infection Prevention and Control Plan was reviewed and updated annually. Cross Refer to Tag A 0772 C. communication and collaboration with the hospital’s QAPI (Quality Assurance and Performance Improvement) Program and follow the hospital’s Infection Prevention and Control Plan. Cross Refer to Tag A 0774 D. the Infection Preventionist (Staff #9) was involved with the Antibiotic Stewardship Program. The hospital failed to follow the “Infection Prevention and Control Plan” Policy. Cross Refer to Tag A 0777”

“INFECTION CONTROL PROFESSIONAL CFR(s): 482.42(a) Infection prevention and control program organization and policies. The hospital must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 48749 Based on document review and interview, the hospital failed to ensure that the infection preventionist/infection control professional (Staff #9) was qualified through education, training, experience, or certification in infection prevention and control. Findings include: A review of the personnel file for Staff #9 revealed that Staff #9 was hired into the Infection Preventionist position on 09/27/2024 for Hospital # 1, Mid Coast Medical Center, Trinity and Hospital # 2. Staff # 9 did not sign the Infection Preventionist job description until 12/17/2024. There was no documentation to support that Staff # 9 was registered for or had completed the Association for Professionals in Infection Control and Epidemiology (APIC) certification. Staff # 9 had no previous education, training or experience in infection control and prevention. Staff #9 was hired in the Infection Preventionist role for Hosptial #1 and Hospital # 2 and there was no documented education, training or experience of infection control and prevention in the personnel file. A review of Hospital # 1 patient census data for October, November, and December of 2024 revealed the following: October- 480 November- 490 December 1st through 17th- 261 A review of the job description titled, “Infection Preventionist” revealed the following requirements: “Job Title: Infection Preventionist Job Summary: The Infection Preventionist (IP) is responsible for identifying, investigating, monitoring, and reporting healthcare-associated infections. The IP collaborates with teams and individuals to create infection prevention strategies, provide feedback, and sustain infection prevention strategies. Qualified Candidate: Educational and Certification Requirements * Licensed or degreed Nurse, public health, epidemiology, clinical laboratory science, medical technology, or related field. * Certification in Infection Control and Epidemiology (CIC, IPC, a -lPC, etc.); preferred. Performance Standards (Job Expectations): 1. Professional Accountability * Pursue professional growth and development of required knowledge and skills. * Maintain certification and licensure requirements. * Establish at least 1 professional goal per year. * Advocate for patient safety, health worker safety, and safe practices. * Participate in an infection prevention and control professional organization/association (i.e.: APIC).” A review of the hospital’s “Infection Prevention and Control Plan” dated 09/2023 revealed the following: “...2. Primary responsibility for the activities of the Infection Prevention and Control Program belongs to the Infection Preventionist. The Infection Preventionist position is within the Department of Nursing. Advanced training in healthcare infection prevention and control is required, including knowledge of prevention, surveillance, and epidemiologic methods. At a minimum, the Infection Preventionist has completed training in Infection Prevention and Control.” An interview with Staff #9 was conducted on 12/17/2024 at 9:05 AM. Staff #9 stated “I did not receive my job description until this morning and I signed it. I was told a little about my duties. The APIC training wasn’t discussed with me until this morning. Staff #9 stated, “I don’t have any infection control background and I am not an experienced hospital nurse.” An interview with Staff #2 (Quality Director, Infection Control Director, and Interim Chief Nursing Officer) was conducted on 12/17/2024 at 10:22 AM. Staff #2 confirmed the Infection Preventionist had received the job description today and not when hired into the position. Staff #2 stated, “Staff #9 has not been registered or attended the APIC training and was looking into pricing. I have not completed the APIC training either. I’ve done the Certification in Infection Prevention and Control (CIC) education, but I failed the test. I don’t have a current certification or Infection Control background. I was a previous Intensive Care Unit nurse.””

“IC PROFESSIONAL RESPONSIBILITIES POLICIES CFR(s): Standard: Leadership responsibilities (2) The infection preventionist(s)/infection control professional(s) is responsible for: (i) The development and implementation of hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 48749 Based on record review and interview, the hospital leadership failed to ensure the hospital’s Infection Prevention and Control Plan was reviewed and updated annually. Findings include: A review of the hospital’s “Infection Prevention and Control Plan” revealed that the policy was last revised on 09/2023. An interview with Staff #2 was conducted on 12/17/2024 at 10:22 AM. Staff #2 stated “The plan was supposed to be updated annually. The ‘Infection Prevention and Control Plan’ was missed because the plan was sent to another staff member and not me. We have it scheduled for January 2025.””

“IC PROFESSIONAL COMMUNICATION QAPI CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (iii) Communication and collaboration with the hospital’s QAPI program on infection prevention and control issues. This Standard is not met as evidenced by: 48749 Based on medical record review and interview, the Infection Control Program failed to ensure communication and collaboration with the hospital’s QAPI (Quality Assurance and Performance Improvement) Program and follow the hospital’s Infection Prevention and Control Plan. No documentation was provided to the Surveyor to support that communication and collaboration occurred between the hospital’s Infection Preventionist and QAPI. A review of the facility’s “Infection Prevention and Control Plan” policy dated 09/2023 revealed the following: “MONITORING: 1. Monitoring the results of the Infection Prevention and Control Program allows the hospital to determine if the processes in place are effective or should be revised. 2. Monitoring is achieved through: 1. Committee interaction, especially the Safety/Risk/Health Subcommittee/Quality Council and Medical Staff Committee. 2. Primary responsibility for the activities of the Infection Prevention and Control Program belongs to the Infection Preventionist. The Infection Preventionist position is within the Department of Nursing. Advanced training in healthcare infection prevention and control is required, including knowledge of prevention, surveillance, and epidemiologic methods. At a minimum, the Infection Preventionist has completed training in Infection Prevention and Control. 3. The Infection Preventionist maintains a close working relationship with Performance Improvement/Quality Assurance for the quality assessment and improvement of patient process/function and will interface through all departments to achieve the goals and objectives of the Infection Prevention and Control Program. 4. The Infection Preventionist will serve on the Safety/Risk/Health Subcommittee/Quality Council and any other committees and teams as indicated. 5. The Infection Preventionist is responsible for: a. Performance Improvement Indicators, Quality Control reports, Statistical data, Disease reporting. b. Policy and procedure reviews. c. Surveys and inspections.” An interview with Staff #2 was conducted on 12/17/2024 at 10:22 AM. Staff #2 stated, “The Infection Control meetings are combined with the monthly Quality meetings. I attend, the Pharmacist and the Director of Nursing. Sometimes Staff #9 will attend.” An interview with Staff #9 was conducted on 12/17/2024 at 11:20 AM. Staff #9 stated, “I have not been involved in any meetings for infection control or quality. I have not attended a monthly infection control meeting or the P&T (Pharmaceutical and Therapeutic) committee meeting””

“IC PROFESSIONAL COLLABORATION CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (vi) Communication and collaboration with the antibiotic stewardship program. This Standard is not met as evidenced by: 48749 Based on record review and interview, the hospital failed to ensure the infection preventionist (Staff #9) was involved with the Antibiotic Stewardship Program. The hospital failed to follow the “Infection Prevention and Control Plan” Policy. Findings include: A review of the “Quality Council Meeting Minutes” dated 11/19/2024 revealed there was no documentation to support the collaboration between the Infection Control Preventionist and the Antibiotic Stewardship Leadership Team. The meeting minutes included all of the corporate hospitals and did not differentiate each hospital’s data. There was no documentation provided to show which hospital staff attended the meeting. An agenda of the Quality Council Meeting minutes dated 12/11/2024 was provided to the Surveyor. There was no documentation provided on the meeting minutes or on who attended the meeting. A review of the schedule for Staff #9 (Infection Preventionist) for November and December revealed that on the dates of the Quality Council meetings, Staff #9 worked a day shift on the medical-surgical nursing floor on 11/19/2024 and a night shift on the medical-surgical nursing floor on 12/11/2024. Therefore, Staff #9 was unavailable for the Quality Council Meeting due to working on the medical-surgical nursing floors. A review of the hospital’s “Infection Prevention and Control Plan” policy dated 09/2023 revealed the following: “Monitoring: 1. Monitoring the results of the Infection Prevention and Control Program allows the hospital to determine if the processes in place are effective or should be revised. 2. Monitoring is achieved through: 1. Committee interaction, especially the Safety/Risk/Health Subcommittee/Quality Council and Medical Staff Committee. 2. Primary responsibility for the activities of the Infection Prevention and Control Program belongs to the Infection Preventionist. The Infection Preventionist position is within the Department of Nursing. Advanced training in healthcare infection prevention and control is required, including knowledge of prevention, surveillance, and epidemiologic methods. At a minimum, the Infection Preventionist has completed training in Infection Prevention and Control. 3. The Infection Preventionist maintains a close working relationship with Performance Improvement/Quality Assurance for the quality assessment and improvement of patient process/function and will interface through all departments to achieve the goals and objectives of the Infection Prevention and Control Program. 4. The Infection Preventionist will serve on the Safety/Risk/Health Subcommittee/Quality Council and any other committees and teams as indicated. 5. The Infection Preventionist is responsible for: a. Performance Improvement Indicators, Quality Control reports, Statistical data, Disease reporting. b. Policy and procedure reviews. c. Surveys and inspections.” An interview with Staff #2 was conducted on 12/17/2024 at 10:22 AM. Staff #2 stated, “The Antibiotic Stewardship and Infection Control meetings are combined in the monthly quality meetings. I attend, the Pharmacist and the Director of Nursing. Sometimes Staff #9 will attend. My instructions were for Staff #9 to focus on Infection Control and not work shifts until trained.” An interview with Staff #9 was conducted on 12/17/2024 at 11:20 AM. Staff #9 stated, “I have not been involved in any meetings for infection control. I have not attended a monthly infection control meeting, the P&T (Pharmaceutical and Therapeutic) committee meeting, or an Antibiotic Stewardship Meeting.””