CMS Manual System - Louisiana Department of Health and Hospitals

Record Review
Review the resident‘s record to determine, for example:
Whether the resident‘s record included an evaluation of the factors which may
increase a resident‘s risk of infection (e.g., indwelling urinary catheters,
intravenous catheters, and tracheostomy tubes), and if an infection is present,
whether the resident‘s record reflects the identification of the infection, potential
causes and contributing factors; and
Whether the resident‘s plan of care identifies interventions (device management
and isolation precaution measures) to prevent the transmission of infection.
Review the facility‘s record of incidents of infection and related corrective actions to help
determine whether the facility is identifying, recording, and analyzing infections.
In order to investigate identified infection control concerns, review, as applicable, the
facility‘s:
Infection control policies to determine if they are consistent with current
professional standards of practice and if the infection control policies are defined
by department (e.g., dietary, nursing, laundry);
Documentation of whether and how the infection prevention and control program
collects, analyzes, and uses data and implements a program to guide all
disciplines to prevent the spread of infections and identify infections in a
standardized and systematic way;
Policies regarding handling and processing soiled linens as well as handling,
transporting, and storing clean linens;
Applied preventive components of the infection prevention and control program
in the care of individual residents;
Policies, procedures, and documentation regarding identifying and prohibiting
contact with residents or food by employees with open lesions or communicable
diseases and addressing occupational communicable disease exposure and postexposure
follow up;
Employee records to determine if employees receive initial and ongoing employee
infection control training regarding critical elements of the infection control plan;
and
Documentation related to their review of the appropriateness and effectiveness of
antibiotics for residents that are identified as receiving antibiotics.