HospitalInspections.org

36293

Based on policy/procedure review, observation and interview, the CAH failed to ensure health care services were furnished according to its written policy/procedures as evidenced by failing to ensure 3 of 3 HemoCue Glucose Cuvette testing bottles were dated upon opening.
Findings:

Review of the CAH procedure titled, " HemoCue Glucose 201 Procedure" revealed in part: Microcuvettes kept in an open vial are stable for 30 days when stored in a refrigerator at 2-8 degrees centigrade.

An observation of the Emergency Department's refrigerator on 11/29/22 at 9:25 a.m. revealed an opened and undated vial of HemoCue Glucose microcuvettes.

In an interview at that time, S4RN confirmed the finding and acknowledged the vial should have been dated when opened so it could be discarded after 30 days.

An observation of the Nursing Department's refrigerator on 11/30/22 at 2:00 p.m. revealed 2 opened and undated vials of HemoCue Glucose microcuvettes.

On 11/30/22 at 2:15 p.m., an interview with S1DON confirmed that the microcuvettes should be dated when opened and discarded within 30 days as stated in the policy.

Based on record review and interview, the CAH failed to provide nursing care in accordance with the patient's needs and the specialized qualifications and competence of the staff available by failing to ensure the Emergency Department staff were trained in non-physical intervention skills for 3 of 3 (S4RN, S5LPN, S7LPN) Emergency Department nursing staff members whose personnel records were reviewed.
Findings:

Review of the personnel records for S4RN, S5LPN and S7LPN revealed they were Emergency Department nurses but had no documented evidence that they had received specialized training in non-physical intervention skills.

On 11/30/22 at 2:00 p.m., interview with S1DON confirmed that the above nurses worked in the Emergency Department and could potentially care for a violent/psychiatric patient. S1DON stated that all nurses working in the Emergency Department should have training in non-physical intervention skills. S1DON further stated that she was aware that none of the nurses in the Emergency Department, including S4RN, S5LPN and S7LPN, had current certification in non-physical intervention skills.

Based on observations and interview, the CAH failed to maintain a clean and sanitary environment to avoid sources and transmission of infection as evidenced by 1) failing to ensure staff sanitized their hands after patient care and 2) failing to ensure equipment was properly cleaned or sterilized after each use.
Findings:

1. On 11/28/22 at 10:30 a.m., observation revealed S2Phlebotemist was drawing blood from Patient #3. Further observations revealed S2Phlebotemist was not wearing any gloves, but was using bare hands. After completing the blood draw, S2Phlebotemist was observed to grab the blood tubes in one hand and the plastic bin that held lab supplies in her other hand, exit the room and begin walking down the hall. S3Phlebotemist was not observed to perform any hand hygiene after the patient care.

On 11/28/22 at 3:35 p.m., interview with S1DON confirmed that all staff should be wearing gloves during blood draws and that hand hygiene should be performed after all patient care.

2. On 11/29/22 at 11:05 a.m., observation revealed S3LPN used a glucometer to check the glucose level for Patient #20. S3LPN placed the glucometer machine on the patient's bedside table as she obtained the patient's blood sample. Further observations revealed that the glucometer machine was not disinfected prior to leaving the patient's room. The surveyor walked back to the nurses station with S3LPN after the above procedure and observed S3LPN to place the glucometer on a rolling cart without disinfecting it.

On 11/30/22 at 9:30 a.m., interview with S1DON confirmed that the glucometer should be disinfected after each use.