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A recertification survey was initiated on 07/30/13 and completed on 08/01/13 to determine the facility's compliance with the Federal Conditions of Participation. Based on survey findings, it was determined the facility did not meet the Federal Conditions of Participation of CRF 482.41, Physical Environment.


Refer to LSC Tags:

K-25, K-27, K-29, K-31, K-33, K-38, K-45, K-46, K-47, K-50, K-52, K-54, K-64, K-69, K-70, K-72, K-75, K-104, K-130, K-132, K-135, K-144, K- 147 and K-155.

Based on direct observation, staff interview and record review, it was determined the facility failed to ensure patient care equipment related to blood glucose monitoring was maintained to ensure accuracy of the equipment.

Findings include:

An interview with the Chief Nursing Officer, on 07/31/13 at 9:05 AM, revealed the facility had no policies and procedures regarding glucometer quality control testing.

During tours of the facility, patient "TRUresult" glucometers were observed in the emergency department, surgery department and the medical floor. Interviews were conducted with the nursing staff on the medical floor, on 07/30/13 at 11:50 AM. The staff could not provide documented evidence that routine quality controls were being performed for the glucometer used in this area. A review of available documentation revealed the last control had been performed over thirteen (13) months earlier on 6/12/12. Observations of the emergency department, on 07/31/13 at 9:20 AM, and the surgery suite, on 07/31/13 at 10:05 AM, also revealed glucometers without documentation of control testing. An interview with the medical floor nursing staff, on 7/30/13 at 11:50 AM, revealed the glucometer was cleaned with alcohol wipes between patient use. However, the staff could not provide documentation this was the method recommended by the manufacturer. Of the three areas observed that had glucometers, only the surgery suite had manufacturer documentation for the use and cleaning of this particular brand of glucometer. Review of this documentation revealed the statement "Cleaning the meter with alcohol WILL cause damage".

Based on observation, interview and record review, it was determined the facility failed to maintain the physical environment to ensure the safety and well-being of patients.

A Life Safety Code survey was conducted on 07/31/13. Life Safety Code deficiencies were cited at 42 CFR 482.11.

Refer to LSC tags:

K-25, K-27, K-29, K-31, K-33, K-38, K-45, K-46, K-47, K-50, K-52, K-54, K-64, K-69, K-70, K-72, K-75, K-104, K-130, K-132, K-135, K-144, K- 147 and K-155.