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Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to utilize appropriate personal protection equipment (PPE) when handling urine sample obtained from 1 of 1 (P21) patient reviewed. In addition, staff failed to ensure common use glucometer equipment was properly disinfected between patients who required blood sugar level testing. These practices had the potential to affect any patients who receive care at the CAH.

Findings include:

P21 was admitted on 8/28/19, with diagnoses from the electronic medical record which included type II diabetes, and a history of Methicillin-resistant Staphylococcus aureus (MRSA) (a bacterium that causes infections and is tougher to treat than most strains of staphylococcus aureus because it's resistant to some commonly used antibiotics).

During observation on 8/28/2019, at 2:45 p.m. registered nurse (RN)-A exited room 709 wearing gloves and carrying a plastic laboratory bag with a specimen container of amber liquid. RN-A identified the liquid as a urine sample from R21. There was no identifying label on either the specimen container or the bag in which it had been placed. RN-A immediately walked across the hall, accessed the medication room, by pushing in the code using her gloved hands and placed the specimen bag on the counter and exited the room. RN-A indicated she had to obtain the label for the specimen from the printer located inside the medication room after it was generated from the computer located in the patient room.

When interviewed regarding the procedure for bringing specimens from an area with contact precautions, RN-A stated she had placed the specimen inside the biohazard bag in the room, but wasn't aware of the need to label the specimen while in the patient's room prior to transferring the specimen to a uncontaminated bag outside the room with the assistance of a coworker. RN-A returned to the medication room, retrieved the bag containing the urine specimen and the identifying label and with her un-gloved hands, RN-A opened the bag and placed the label on the surface of the container. RN-B assisted by holding a new laboratory biohazard bag open so that RN-A could place the original bag with the specimen into it for transfer to the laboratory through the vacuum system. RN-A confirmed R21 had been placed on contact precautions due to having a history of MRSA.

During interview on 8/28/19, at 3:15 p.m. the infection control practioner (ICP) confirmed she would expect staff to follow facility policies and procedures of having a second person assist in receiving items from inside a patient room with contact precautions. She further confirmed staff received annual education on infection control, PPE and review of facility policies for working with patients under precautions. The ICP verified RN-A had not followed the facility policy for handling and labeling specimens, prior to bringing them from the patient room, and the additional precautions necessary for a patient receiving contact precautions. The ICP verified the facility policy for contact precautions were to be initiated at the time of admission for a patient with a history of MRSA.

R21's current medical record contained physician orders for blood glucose checks every (Q) 6 hours (H), which required staff to take the common use blood glucose meter into R21's room.

RN-C was interviewed on 8/29/19, at 10:10 a.m. and provided a demonstration of the cleaning process utilized for glucose meters. RN-C demonstrated the following process for checking a blood sugar:
1.) The meter was retrieved from the docking station, located on one of the nursing alcoves, and the lancet, test strip and monitor were taken into the patient room,
2.) The patient's blood sugar was checked using clean technique, the soiled test strip and lancet were disposed of in the in room sharp's container and the meter was brought back to the nursing alcove.
3.) The meter surface was wiped with a gray top Sani-cloth.

RN-A demonstrated the procedure for cleaning of the blood glucose monitor:
1.) RN-C applied gloves, removed a wipe from the grey top Sani-Cloth container, wiped over the surface of the meter, no hesitation or delayed contact between the wipe and the meter.
2..) Immediately after wiping the outside surface of the meter with the cloth it was returned to the charger base to dry. When asked about drying time following being wiped with the grey tope Sani-Cloth, RN-C indicated she thought it probably took 10 - 15 seconds to dry, but she had never timed it and was not aware of the manufacture's instructions for the surface to remain wet for 3 minutes, before being allowed to dry.

On 8/29/19, at 10:20 a.m. during a group interview, RN-D and RN-E were also interviewed on their process for disinfecting the common use glucometer and they both confirmed they followed the same procedure of obtaining a wipe from the grey top Sani-Cloth container, wiping over the surface of the meter with no delay in contact time and then immediately replacing the meter into the charger. Both RN-D and RN-E verified they were not aware of the manufacture's recommendations located on the back of the container recommending a 3 minute surface dry time. RN-D retrieved the facility policy on her computer and verified staff was not following the indicated procedure which listed specific directions in addition to the process for when the meter was utilized for a patient on contact isolation.

On 8/29/19, at 10:15 a.m. ICP verified staff should be following the manufacture's recommendations for "wet" time when utilizing the Sani-Cloth gray top wipes which listed a 3 minute wet time to provide disinfection and this was not being followed with glucometer usage.

Review of the facility policy included for persons with MRSA to be placed on contact precautions with appropriate PPE utilized. The policy: Specimen Handling and Transport 94.80 dated 4/23/19 directed Standard Precautions used for handling of all specimens.

Review of the facility policy Nova Statstrip Whole Blood Glucose Meter 49.112 with the last revision date of 3/26/19: Test for a Patient in contact isolation:
Take the meter, 2 test strips, and 2 lancets into the room with you. ; When test is completed, discard both test strips and other disposables. Place the meter on the isolation cart or other horizontal surface. Return to patient's room and remove and dispose gloves and gown in patient's room.; wash hands; dispense 2 Sani-cloth wipes or Sani-cloth bleach wipes.; return to the isolation cart or other horizontal surface. Using a squeezed out Sani-Cloth or Sani-cloth Bleach wipe, pick up the meter and wipe the meter 3 times horizontally and 3 times vertically. Be careful not to contaminate clean surfaces. Wipe the surface where the dirty meter had been places with a Sani-cloth wipe. Discard the used wipe. Wash hands.

Undated manufacturer guidelines for disinfection: PDI® Sani-Cloth® AF3 Germicidal Disposable Wipes : Label directions found on the back of container for contact time: Cleaning procedure: All blood and other body fluids must be thoroughly cleaned from surfaces and objects before disinfection by the germicidal cloth. Open and unfold first germicidal cloth to remove heavy soil. Contact Time: Use second germicidal cloth to thoroughly wet surface. Allow to remain wet three (3) minutes, let air dry. Although efficacy at a 30 second contact time has been shown to be adequate against HIV-1 (AIDS VIRUS), this time is not sufficient for the other non-HIV organisms listed on this label. Therefore, a 3 minute wet contact time must be used for all listed non-HIV organisms.

Based on interview and document review, the critical access hospital (CAH) failed to ensure medication errors and adverse drug reactions were incorporated into the CAH's Quality Assurance Performance Improvement (QAPI) program. This had the potential to affect all patients receiving services from the CAH.

Findings include:

Review of the pharmacy's current QAPI projects for 2019, did not include any medication errors or adverse drug reactions (ADR's).

On 8/28/19, at 11:30 a.m. the director of pharmacy identified various QAPI projects the pharmacy was currently working on and confirmed medication errors and ADR's had not been incorporated into the CAH's QAPI program. She indicated medication errors and ADR's were reviewed with the hospitals pharmacy and therapeutics committee (P&T,) and medication safety committee on a monthly basis.

On 8/29/19, at 8:55 a.m. the quality manager confirmed the hospitals medication errors and ADR's had not been incorporated into the CAH's QAPI program. The QM confirmed the hospitals medication errors and ADR's were only reviewed with the P&T committee and medication safety committee.

Review of a facility policy titled, Medication Administration and Medication Variance TRF dated 8/19/19, revealed the CAH's medication errors were reviewed by the CAH's medication safety committee as a part of the hospital's continuous improvement process. The policy did not identify medication errors were to be integrated into the CAH's QAPI program.