HospitalInspections.org

The Condition of Participation for Quality Assurance and Performance Improvement (QAPI) is not met based on the facility not having an effective quality program to develop, implement and maintain an ongoing, hospital-wide, data-driven quality assessment and performance improvement program related to infection control in the facility.

These failures present a substantial probability to adversely affect all patients' physical health and well-being.



The findings include:


The facility's Infection Control Program (Refer to A0749)

Based on observations, record reviews, and staff interviews, the Condition of Participation (COP) was not met for Infection Control based on the hospital's failure to follow Policy and Procedures related to Infection Control, as well as the Centers for Disease Control and Prevention guidelines to ensure contaminated reusable equipment (blood glucometers) were cleaned and disinfected between each patient's use to prevent the spread of blood borne pathogens for 2 out of 3 glucometers observed in the Emergency Department. (2) Failed to follow infection control practices to properly perform a dressing change for a Peripherally Inserted Central Catheter (PICC) line for 1 (#8) out of 3 patients observed for dressing changes.


Breaks in Infection Control Practices related to blood glucose monitoring and non-adherence to infection control practices during patient care place patients at risk for outbreak of blood borne diseases.


These failures resulted in the Condition of Participation for Infection Control.




The findings include:

(See A0749)

Based on observations, record reviews, and staff interviews, the hospital failed to follow Policy and Procedures as well as the Centers for Disease Control and Prevention guidelines to ensure contaminated reusable equipment (blood glucometers) were cleaned and disinfected between each patient's use to prevent the spread of blood borne pathogens for 1 (#11) out 4 patients sampled for blood glucose monitoring, and for 2 out of 3 multi-use glucometers observed in the Emergency Department. In addition, nursing staff failed to follow infection control practices to properly perform dressing changes for a Peripherally Inserted Central Catheter (PICC) line for 1 (Patient #8) out of 3 patients observed for dressing changes.


The findings include:


An observation was conducted on 5/2/2018 at 11:00 am of Employee D obtaining a blood sugar from a patient (#11) in the Emergency Department. Employee D placed the glucometers (Nova Stat Strip), removed her gloves, sanitized her hands and walked out of the patient's room. The employee then walked over to the counter at the Nurses' Station charting area, placed the glucometer on the counter and walked away. The employee was observed washing her hands. Employee D then returned and picked up the glucometer and placed it into the facility's docking station (a device that transmits the blood sugar results to the facility's computer system). Employee D did not clean or disinfect the glucometer before she placed it on the docking station.



An interview was conducted with Employee D on 5/2/2018 at 11:05 AM. Employee D was asked how often she cleansed and disinfected the blood glucometer. She replied, " I do it if it's soiled and then every 3 to 4 days, I guess." The employee was asked when did she clean the glucometer and what did she clean it with, she replied, "I would use alcohol wipes."


On 5/2/2018 at 11:07 AM, the glucometer that was not cleaned or disinfected by Employee D was removed from the docking station and a dried, red/brown colored substance (which resembled blood) was observed on the front surface of the glucometer. (photographic evidence obtained).



An interview on 5/2/2018 at 11:08 AM with Employee B, RN, confirmed the substance on the glucometer appeared to be dried blood and all staff should clean and disinfect the glucometer before and after each patient's use with approved hospital bleach wipes.


An observation was conducted on 5/2/2/108 at 11:12 AM of a glucometer docking station located in the West Unit of the Emergency Room. An observation of the glucometer that was docked in the station revealed multiple red/brown colored substances (which resembled blood) dried on the surface of the glucometer and also inside the docking station. (photographic evidence obtained).


An interview with Employees B & E, RNs on 5/2/2018 at 11:13 AM confirmed the dried blood-like substance on both docking stations and the glucometer located in the West Wing of the Emergency Department.


A review of the Emergency Department Check Sheet Log revealed the Emergency Department glucometers were checked daily by staff. A review of the log dated 5/2/2018 revealed Employee D initialed that the glucometers were checked.


An interview with Employee C, RN on 5/2/2018 at 11:20 AM stated the staff initial the Check Sheet when they perform calibrations (quality controls) on the glucometers each morning and Employee C remarked, " I would think they would clean them as well, but it doesn't look like that is being done."



An interview with Employee D, on 5/2/2018 at 11:21 AM confirmed she initialed the Check Sheet that she performed her daily quality controls, but did not clean and disinfect the glucometers at that time.


An interview with the Hospital Infection Control Officer on 5/2/2018 at 1:30 PM confirmed blood glucometers should be cleaned before and after each patient's use with the facility's bleach wipes (Sani-Cloth bleach wipes).


A review of the hospital's Policy and Procedures for Cleaning & Disinfection of patient care equipment if 58 effective date 6/84, and review date of 11/2017 read, " Patient care equipment (glucometers) managed by patient care units must be disinfected by approved detergent/disinfectant before removal from patient's room, and after use by each patient, by the healthcare worker using the equipment."


An interview on 5/3/2018 at with Employees C & F, Registered Nurses (RN) confirmed the glucometers should be cleaned before and after each patient's use. Employee C confirmed the RN was ultimately responsible for the oversight of the technicians, but didn't realize there was an issue with cleaning the glucometer until 5/2/2018, when discovered by this Surveyor.


A review of the Centers for Disease Control and Prevention (CDC) guidelines for "Infection Prevention during Blood Glucose Monitoring and Insulin Administration," revealed the following, "The Centers for Disease Control and Prevention (CDC) have become increasingly concerned about the risks for transmitting Hepatitis B Virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration.
"...whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared.
...Outbreaks of Hepatitis B Virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity."


2) An observation was conducted on 5/3/2018 at 9:45 AM of Employee G, RN, performing a dressing change on Patient #8's (Peripherally Inserted Central Catheter) PICC line. The employee was observed removing the patient's old dressing and proceeded with the dressing change without removing gloves, performing hand hygiene or changing gloves.


An interview with Employee G, RN on 5/3/2018 at 9:57 AM confirmed she should remove her gloves and wash her hands after removing the soiled dressing and failed to do so when she removed the dressing from Patient #8's PICC line.


An interview with Employee E, RN on 5/3/2018 at 9:58 AM, confirmed employees should remove gloves and perform hand hygiene and apply sterile gloves after a soiled dressing was removed during a PICC line dressing change.


A review of the facility's Policy and Procedures for Care of Patient with Central Lines, NG 139 Purpose maintain the Central line catheter properly so the patient will have a dependable safe route for long term Intra-Venous therapy and the central line will remain patent and free of infection. Cleaning of PICC line was referenced to Perry and Potter Clinical Nursing Skills and Techniques.


A review of Perry and Potter Clinical Nursing Skills and Techniques for changing a dressing of a PICC line revealed, "Perform hand hygiene and don gloves; Remove the old dressing by lifting the edges of the dressing beginning at the catheter hub and gently pulling the dressing toward the insertion site; Remove gloves, perform hand hygiene and don sterile gloves.