Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 531311 (X3) Date Survey Completed 11/17/2011
Name of Provider or Supplier Crook County Hospital Street Address, City, State 713 Oak Street, Sundance, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
C0278 PATIENT CARE POLICIES
CFR(s): 485.635(a)(3)(vi)

[The policies include the following:] a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.


This STANDARD is not met as evidenced by:
Based on staff interview, and review of medical records, laboratory reports, hospital policies, and infection surveillance activities, the facility failed to maintain accurate and complete surveillance records for 2 of 5 sample patients (#13, #19) specifically reviewed for infection control concerns. The findings were: Medical records for 5 patients identified with infections or antibiotic therapy were reviewed on 11/15/11 and 11/16/11. Laboratory reports and infection control logsheets were similarly reviewed to determine the accuracy and continuity of infection surveillance activities. The concomitant review of clinical and infection information revealed the following deficiencies: a. Progress notes, physician orders, and laboratory reports in patient #13's medical record showed s/he received 5 antimicrobials (ciprofloxacin, Zosyn, vancomycin, Flagyl, Rocephin) in a 10 day period, January 5-14, 2011. Of these 5 antimicrobials, 3 were administered less than 48 hours before being discontinued; the discontinuance was attributed to antibiotic resistance in an Escherichia (E.) coli isolated from the patient's urine. Review of the patient's laboratory results dated 1/8/11 showed a urine culture positive for a multi-drug resistant E. coli. The culture isolate demonstrated resistance to flouroquinolone, aminoglycosides, and selected penicillin and cephalosporin antibiotics. Infection surveillance reports were reviewed on 11/16/11 at 3:40 PM with the infection control nurse. The January 2011 surveillance record reported that patient #13 received a single antibiotic, ciprofloxacin, and did not have any positive culture results. The infection control nurse stated in interview on 11/16/11 at 3:55 PM she received reports from the nursing staff and, in this case, the information was incomplete. The infection control nurse acknowledged the surveillance data for patient #13 was not an accurate and complete record of the patient's antibiotic therapy and culture results. b. A physician's progress entry dated 1/24/11 for patient #19 noted the patient had "...MRSA [methicillin-resistant Staphylococcus aureus] positive Staph pneumonia..." Review of laboratory results and infection surveillance records for January 2011 failed to uncover any evidence to show the patient was culture positive for MRSA. A previous progress note, dated 1/16/11 and entered by a different physician, stated the patient was being treated prophylactic to cover the potential for resistant Staph infection. The 11/16/11 physician entry further stated there was no need to perform cultures. The infection control nurse stated in interview on 11/16/11 at 4:40 PM she was not aware discrepant reports existed in the patient's record. She further stated she did not routinely review physician progress notes as part of the infection surveillance program; she expected this information to be reviewed by the nursing staff and reported to her as necessary. She acknowledged that in the case of patient #19 there was no report of a MRSA infection. Crook County Medical Services District policy IC 005, Infection Control Program, revised and accepted 10/13/10, required staff to identify and monitor infections and antibiotic treatment among patients. Interview with the CNO on 11/16/11 at 5:15 PM revealed her expectation that nursing staff review provider notes and seek clarification from providers when questions or discrepancies exist.