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)
C0338 QUALITY ASSURANCE
CFR(s): 485.641(b)(2)

[The program requires that--] nosocomial infections and medication therapy are evaluated;


This STANDARD is not met as evidenced by:
Based on staff interview and review of policies, procedures, medical records, and infection surveillance activities, the facility failed to effectively evaluate information available to the infection control program on antibiotic therapy and culture reports. The findings were: 1. Review of infection control records on 11/15/11 and again on 11/16/11 revealed incomplete and inaccurate information on patient antibiotic therapy and culture reports. Although the infection program systematically reported monthly summaries of surveillance data, there was no evidence to show the program evaluated the accuracy of its reporting system or validated its data collection process. The following discrepancies were discovered: a. As detailed in C278, the hospital infection control program failed to recognize incomplete antibiotic therapy entries for patient #13 and, further, failed to identify and monitor culture findings on the same patient. As described in C302, the patient's record lacked a discharge summary of significant clinical findings related to a urinary tract infection and antimicrobial therapy. b. The infection control program failed to identify and resolve a discrepancy in the medical record of patient #19 that alleged the patient was positive for MRSA pneumonia. As detailed in C302 and C278, the hospital lacked a competent system for identifying potential inaccuracies in medical records and assessing their impact on infection surveillance activities. 2. The infection control nurse stated in interview on 11/16/11 at 3:45 PM that she received infection surveillance worksheets from the nursing staff; the information reported on these worksheets prompted her further investigation of infection concerns and antibiotic use. She acknowledged the existing data collection technique was incomplete in the instances cited with patients #13 and #19. The infection control nurse stated clinical records were not routinely audited to asses the accuracy and completeness of infection surveillance data. 3. 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.