HospitalInspections.org

Based on policy and procedure reviews, review of hospital's General Unit Inspection Form, observation, and staff interviews, the hospital staff failed to ensure infection control policies were followed by improper cleaning and disinfecting glucometer (machine to test patients' blood glucose levels) in 1 of 1 glucometers observed and failed to disinfect exam rooms after use in 2 of 4 rooms.

The findings include:

Review of hospital policy titled "Glucometer" with revision date of 02/2016, revealed, "...The glucomter machine is to be cleaned and disinfected in between patients. This is to be completed as follows: a. After completing patient testing and recording the result, the entire glucometer machine must be wiped with a Micro-Kill or Super-Sani cloth Wipe (EPA-registered Hospital Grade Disinfectant Wipe). b. The entire machine must then be wrapped in a clean Micro-Kill or Super-Sani cloth Wipe for 2 minutes. Remove the wipe from the glucometer machine after 2 minutes; allow glucometer machine to dry before performing the next patient test."

Review of facility's Infection Control "General Unit Inspection" dated December 2017, revealed, "0/7 (zero out of 7 staff members) knew how long product's 'wet time' was. Reeducated."

Observation on 01/09/2018 at 1200 of patient care floor revealed RN #1 removed glucometer from dried sani wipe then performed fingerstick on patient. Further observation revealed RN #1 removed the correct wipe from Red top wipe bottle, labeled Sani wipe, and placed the wipe onto the glucometer without wiping glucometer machine. Further observation revealed RN #1 then performed the next patient's fingerstick immediately using the same glucometer without wiping the glucometer. Further observation revealed administrative staff member #4 (AS) observing RN #1 during the fingerstick.

Interview on 01/09/2018 at 1205 of RN #1 revealed "I should have wiped it down. We are taught to wipe it for 10 minutes."

Interview on 01/09/2018 at 1210 with AS #4 revealed staff are taught to clean glucometers per policy. Further interview revealed policy was not followed.

Interview with AS #3 on 01/09/2018 at 1530 revealed she does rounds on the units and reports findings to administrative staff and was aware of staff not following policy.





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2. Review of hospital policy "Prevention and Control of Infection in Exam Rooms" on 01/09/2018 reviewed 2/2016 revealed "PROCEDURE ...2. Disposable paper sheets are to be removed after each patient and discarded...6. Floors and counter tops are to be cleaned on a daily basis by Housekeeping. Cabinets and the exam table are to be clean and kept free from dust on a daily basis...7. Waste baskets are to be emptied daily and cleaned plastic liners replaced by Housekeeping..."

Observation during tour on 01/09/2018 at 1022 revealed exam room on (1 East) had debris on the floor which included paper, broken pen parts, broken cart lock and dust. Observation also revealed disposable tissue paper on exam table was not discarded after patient use and dust on the blood spill kit.

Interview with AS (Administrative Staff) #1 on 01/09/2018 at 1022 during tour revealed the exams rooms are cleaned daily and the housekeeper assigned to clean the room was not on duty due to car trouble.

Interview with AS #3 on 01/09/2018 at 1530 revealed she does rounds on the units and reports findings to administrative staff. Interview revealed her round reports have identified the cleanliness of the exam rooms to include changing of the exam table paper.

Observation during tour on 01/09/2018 at 1040 revealed exam room (Room 1162) with 1 full biohazard (red trash bag) on the floor and another trash can with overflow. Observation also revealed disposable tissue paper on exam table was not discarded after patient use.

Interview with AS #2 on 01/09/2018 at 1040 revealed Housekeeping probably have not made rounds. Staff can call them to come get the trash.

Interview with AS #3 on 01/09/2018 revealed she does conducts rounds on the units and reports findings to administrative staff. Interview revealed her round reports have identified the cleanliness of the exam rooms to include changing of the exam table paper.


NC00134092
NC00134613