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 11/13/2013
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 infection control activities, the facility failed to implement an effective system for identifying and reporting diseases and epidemiologically significant conditions to the Wyoming Department of Health. The deficiency was evident in late reporting for 2 of 5 State-mandated reportable conditions (patients #1 and #2), failure to submit 1 of 1 bacterial isolates for confirmatory testing (patient #2), and failure to provide timely follow-up information requested by the health department. In addition, 4 of 5 patients (#2, #3, #4, #5) had incomplete reporting records. The facility further failed to ensure the infection preventionist (IP) had sufficient education and training to direct the infection control program. The findings were: 1. On 11/13/13 beginning at 8:05 AM infection control activities were reviewed with the hospital infection preventionist (IP). Evidence gathered from document review and interview revealed the following deficiencies in the infection control program: A. A sample of patients with reportable diseases and conditions occurring in 2013 were reviewed. Of 5 individuals with infections or conditions that require reporting to the Wyoming Department of Health within 24 hours, 2 (patients #1 and #2) were reported late. Patient #1 had a diagnosis of cryptosporidiosis confirmed on 11/9/13 and reported to the State on 11/12/13. Patient #2 had a diagnosis of campylobacteriosis identified on 7/16/13 and reported to the State on 7/25/13. The IP confirmed in interview on 11/13/13 at 10:40 AM that the conditions were not reported to the State in a timely manner. Subsequent interview with the laboratory manager on 11/13/13 at 2:20 PM further confirmed the dates of diagnostic findings and reporting to the State; she stated the late reports were an oversight. B. Of 5 patients with reportable conditions in the survey sample, 4 (patients #2, #3, #4, and #5) had incomplete reporting records. State Statute (Chapter 35, Section 35-4-107) requires specific documentation to accompany disease reports; the 4 incomplete records lacked one or more data elements for patient demographics, contact information (address or telephone number), occupation, record of hospitalization, and dates of reporting. The IP confirmed in interview on 11/13/13 at 10:50 AM the required reporting information was missing from the 4 records cited. C. One patient (#2) was diagnosed with a bacterial infection that, in additional to notifying the State Health Department, required submission of an isolate to the State Public Health Laboratory for confirmatory testing. Information solicited from the Infectious Disease Epidemiology Program, Wyoming Department of Health, was reviewed on 11/13/13. The information revealed that the facility failed to submit a bacterial isolate to the Public Health Laboratory for testing. The laboratory manager confirmed in interview on 11/13/13 at 3:45 PM that a bacterial isolate was not submitted to the Public Health Laboratory. D. On 11/13/13 email correspondence and telephone logs solicited from the Infectious Disease Epidemiology Program, Wyoming Department of Health were reviewed. These documents showed that 9 requests for additional information on patient #2's infection were made to the hospital between 7/25/13 and 8/15/13 (16 days) before the hospital replied with the requested information. Per telephone interview with epidemiologists #1 on 8/22/13, the facility's failure to reply in a timely manner prevented completion of an open investigation for 25 days beyond the point of initial diagnosis. The timeline reported by the epidemiologist was confirmed in interview with the laboratory manager on 11/13/13 at 3:50 PM. E. Hospital policies and procedures on mandatory reporting were reviewed with the IP on 11/13/13 beginning at 9:15 AM. The current procedure, last reviewed and updated 3/25/09, was discovered to contain outdated references to mandatory reporting requirements. The procedure further failed to identify how mandatory reporting was accomplished and how the process was managed for compliance. There was an absence of direction for follow-up and accountability for prompt and accurate reporting. The IP acknowledged there was no central register or log to track reportable diseases, nor was there an established method of communicating disease reporting to the IP. Without a central log and effective communication, the IP stated she was unaware when reporting was required and if it was completed. 2. Interview with the IP on 11/13/13 beginning at 1:15 PM revealed she had been assigned responsibility for the infection control program 12 months ago. She stated her education and training prior to assuming the roles and responsibilities of the IP did not include include infection control principles beyond that provided in her nursing education. She further stated she had not completed any supplemental training in infection control in the past 12 months. She expressed a desire for training to improve her ability to direct the infection control program.