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Based on observation, staff interview, and policy review, the CAH failed to maintain an adequate system to identify and implement appropriate interventions to prevent the spread of infection for 1 of 1 patient (P1) who received blood glucose testing by the use of a glucometer. Findings included:

The CAH failed to ensure adequate disinfection of glucometer used for multiple patients.

On 3/24/2010, at 9:30 a.m. RN-A was observed to complete a blood glucose test with a glucometer for P1. No cleansing or disinfecting of the glucometer was observed prior to use. Following this, RN-A was observed to take the glucometer back to the medication room and place it into the storage case, without cleansing or disinfecting it.

At this time, RN-A stated the glucometer was for multi -use but only one patient used it presently. She indicated she never really had to clean it because no obvious blood was on it when she used it. RN-A indicated if she needed to clean the glucometer, she could use the alcohol wipes that were in the case where the glucometer was stored.

A policy titled "Glucometer Protocol & Disinfection" dated 2/20/10, was provided by the facility for review. Under Procedure #1: Before using Glucometer to test patients/residents blood glucose you must clean glucometer with Bleach wipes, Sani-wipes, or Alcohol wipes before and after each use.

On 3/24/2010, at 1:00 p.m. the infection control nurse was interviewed. She indicated she had recently written the policy for cleansing and disinfection of the glucometer but had not introduced it to the acute care hospital or the senior care unit. She verified the staff should be cleansing and disinfecting the glucometer after each use. She also verified the glucometer are multi-use.


On 3/25/2010, at 1:30 p.m. the director of nursing was interviewed. She verified the policy for glucometer cleansing and disinfecting was confusing and staff would not know what to use.
At 1:45 p.m. on 3/25/10, the Charge Nurse of the Acute Care indicated that the hospital staff was directed to clean the glucometer with Sani-Wipes.
At 2:00 p.m. a register nurse (RN-B) was interviewed and verified she cleaned the glucometer with Sani-Wipes before and after use.

On 3/25/2010, at 3:30 p.m. the director of the senior care unit was interviewed. She indicated the infection control nurse had sent out the new policy regarding glucometer yesterday at 4:09 p.m. The director had shared the information with her staff and had staff meeting to inform them of the policy. She verified the staff should be disinfecting the glucometer after each use.

Based on interview and record review the facility failed to develop a Quality Assurance (QA) program that evaluated the quality and appropriateness of the facility's outpatient services. Findings include:

The facility did not have a QA program for their Rehab outpatient programs.

The Occupational Therapist (OTR/L-A), who conducted Cardiac Rehab was interviewed at 11:30 a.m. on 3/25/10, and indicated the Cardiac rehab department did not have a current QA project.

The Manager of the Rehab Services was interviewed at 3:00 p.m. on 3/25/10, and verified there was not a QA program for Cardiac Rehab, Outpatient Physical and Occupational Therapy.

Based on record review, policy review, and staff interview the CAH failed to ensure each entry into the medical record was authenticated with a signature, date, and/or time of the entry for 4 of 30 (P2, P3, P4, P5) patients medical records reviewed. Finding included:

Four medical records, that included observation and emergency patient records, lacked authentication with a signature, date and or/time the entry was made in the medical record.

Record review revealed that P2 was seen in the Emergency Department on 1/23/10. Review of the physician order sheet indicated P2 had been prescribed seven medications, four laboratory tests, and one Radiology exam ordered. The orders were not timed or dated.

On 3/25/10, at 9:30 a.m. the Charge Nurse was asked to review the orders and physicians signature. The charge nurse indicated that the physician was MD-1 but that there was another doctors had also written orders (MD-2) but had not signed, dated or timed the order either.

At 10:00 a.m. the Emergency Department Manager (PAC-1) was asked to review P2's physician order sheet. PAC-1 verified that two doctors had written orders and only one had signed the order form. PAC-1 stated "You absolutely can't tell who did what or when."

Record review revealed that P3 was admitted to a observation bed on 3/22/10. A order dated 3/24/10, to change the patient to a "Full Admit" and for several labs and medications was not timed as to when it was written.

Record review revealed that P4 was seen in the Emergency Department 3/18/10. Review of the physician order sheet indicated P4 had been prescribed 4 doses of Intravenous (IV) Ativan, 2 doses of IV Valium and 1 dose of Inapsine IV. The physicians order were not dated, timed or signed by the prescribing physician.

Record review revealed that P5 was seen in the Emergency Department 3/18/10. Review of the physician order sheet indicated P5 had been prescribed 4 laboratory tests, 4 medications and 2 Radiology exam ordered. The orders were not dated, timed or signed by the prescribing physician.

The CAH's "Rules and Regulations Of The Medical Staff" last revised 2008, stated in D. Medical Record. bulletin 9. "All clinical entries in the medical record must be legible. Time and date are to be indicated and all entires must be authenticated by the responsible party."

Based on interview and record review the facility failed to develop a Quality Assurance (QA) program that evaluated the quality and appropriateness of the facility's swing bed services. Findings include:

The facility did not have a QA program for their Swing Bed program.

The facilities Quality Manager and Quality Registered Nurse were interviewed on 3/25/10, at approximately 1:30 p.m. and indicated they were unaware of any QA project involving the Swing Bed Services.

The facility Chief of Operations was interviewed at approximately 3:30 p.m. on 3/25/10, and indicated in June of 2009 the hospital had a outside consultant review the facility swing Bed program, and although the consultant had found that the facility was not unitizing the service to its highest potential, the hospital failed to develop a QA project to review and monitor its services.