HospitalInspections.org

Based on policy review, observation and interview, the hospital failed to ensure staff implemented measures for the prevention of infections and communicable diseases for 1 of 4 (Observation #2) hand hygiene observations and 1 of 1 (Observation #1) blood glucose monitoring observation.

The findings included:

1. Review of the hospital's "Hand Hygiene - Hand-Washing" policy revealed, "...Hands shall be washed before and after each patient contact (even if gloves are worn)..."

Review of the hospital's "Bedside Blood Glucose" policy revealed, "...PROCEDURE: (FOR PATIENT PREPERATION [preparation] AND SPECIMEN COLLECTION)...Tester Preparation - Wash hands and put on disposable gloves prior to testing...EQUIPMENT AND MATERIALS...Preparation...Clean the meter with a cloth that has been dampened with a 10% bleach solution or disinfectant Sani-wipe. Immediately follow with a water-dampened cloth to remove all cleaning residue..."

2. Observations in Pre-Operative Room #9 on 2/26/19 at 8:23 AM revealed Nurse #1 taped down Outpatient #5's intravenous tubing, typed on the computer and then obtained the glucometer from a case with her bare hands. Nurse #1 then donned gloves without performing hand hygiene and pricked Outpatient #5's finger with a lancet to perform blood glucose monitoring. Nurse #1 disposed of the lancet in the sharps container, removed her gloves and documented the result of the blood glucose monitoring in the computer. Nurse #1 did not perform hand hygiene during this process. Nurse #1 placed the glucometer back in the case, took the case to the surgery medication room, and placed the glucometer in a docking station in the medication room. Nurse #1 did not clean the glucometer at any time during this process.

3. During an interview in the hallway by the surgery nurses' station on 2/26/19 at 8:53 AM, the Quality Standards and Regulatory Compliance Coordinator confirmed Nurse #1 did not perform hand hygiene before she donned gloves for blood glucose monitoring and did not clean the glucometer before or after using the glucometer for Outpatient #5. The Quality Standards and Regulatory Compliance Coordinator stated Nurse #1 should have performed hand hygiene prior to donning gloves and should have cleaned the glucometer with the Sani-wipes in the room before and after use.

During an interview in the surgery medication room on 2/26/19 at 8:56 AM, Nurse #1 stated staff cleaned the glucometer once a day in the evening. Nurse #1 stated the surgery staff in the pre-operative area had one glucometer which was used for all patients who needed blood glucose monitoring. Nurse #1 confirmed she did not clean the glucometer before or after use for Outpatient #5.