Volume 2025 | No. 2
SURVEYOR
CRITICAL ACCESS HOSPITAL
CHAPTER 18: INFECTION PREVENTION AND CONTROL AND ANTIBIOTIC STEWARDSHIP 18.02.01 Risk mitigation measures for infection prevention Frequency of the citation: 78% Overview of the requirement: The hospital has documented policies and procedures addressing management of infection risks through maintenance of a sanitary environment and mitigation strategies to minimize person-to-person transmission of infectious disease. Comment on deficiencies: This broad standard is assessed through observation, response to interviews, and document review. Most deficiencies were observable issues of cleanliness. Examples of ACHC Surveyor findings: ■ Equipment in the ER was observed to have an accumulation of dust on top: ice machine, blanket warmer, pyxis. Rust was observed on equipment: CO2 tank, tables, IV pole casters. ■ Staff personal items were intermingled with patient supplies in the lab storage area and medical-surgical unit. ■ In the pharmacy, multiple signs were posted that were not laminated or within a protective, cleanable cover. ■ Ten of fifteen drawers in the medical-surgical patient nutrition area contained dirt, dust, crumbs, and debris. The outside of the cabinets and drawers were visibly dirty. ■ An IV pump in patient room xx, which was clean and ready to use, had a sticky film on the majority of the front face of the pump. ■ Clean chemo and biohazardous waste containers intended for use in patient care bays were stored in the oncology dirty utility room.
Compliance tips for:
This is always a frequent deficiency because it applies to all areas of the hospital and ties infection prevention efforts directly to a sanitary environment. The key to compliance is for all staff to take ownership of observing for and acting on environmental maintenance. ■ Encourage all staff to observe for and report a dirty environment and call for cleaning. ■ Observe for damage to surfaces (floors, walls, doors) and rust on equipment and follow process for what to do when it is observed. ■ Emphasize the link between environmental cleanliness and infection prevention in training for environmental services/housekeeping staff. ■ Create infection control quality goals related to a sanitary environment for departments with deficiencies.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
We’re here to help. To learn more, visit our website at achc.org , call us at (855) 937-2242 , or email customerservice@achc.org .
achc.org | (855) 937-2242 | 61
60
Made with FlippingBook - PDF hosting