HospitalInspections.org

Based on observations, review of manufacturer's recommendations for glucometer and staff interviews, the nursing staff failed to maintain the facility in a manner to ensure an acceptable level of safety and quality by failing to perform controls on a glucometer used for performing patient glucose checks (finger stick blood sugar checks) for one of one glucometer.

The findings include:

Interview on 11/19/2014 at 1400 with AS (Administrative Staff) #2 revealed no hospital policy for performing finger sticks or performing controls.

Review of Manufacturer's recommendations revealed "Use only Bayer's CONTOUR control solutions (Normal, Low or High) with your CONTOUR meter. Using anything other than CONTOUR control solution could present incorrect results. Run a control test: When using your meter for the first time; To check if you are testing correctly; When you open a new vial of test strips; If you leave the test strip vial open for an extended period of time; If you think your meter may not be working properly; or If your test results do not match how you feel....Compare your control test result with the Normal Control Range printed on the test strip bottle label or on the bottom of the test strip box....If your control test result is out of range, do not use your meter for blood glucose testing until you resolve the issue. ..."

Observation during tour on 11/18/2014 at 1415 revealed a Bayer CONTOUR blood glucose meter. Observation failed to reveal any control solutions or a log of control checks.

Interview with CNA (Certified Nursing Assistant) #4 on 11/18/2014 at 1415 revealed she had not performed controls on the meter. Interview revealed since "I have been here for the past 90 days, I have not seen an instruction book, no controls, or date on top of test strips. I have not done controls at this job."

Observations on 11/19/2014 at 1145 revealed CNA #4 using a Bayer CONTOUR glucose meter to check a patient's blood glucose. Further observation revealed no control solution available.

Interview with AS (Administrative Staff) #2 on 11/19/2014 at 1430 revealed high, low and normal control solutions were now available. AS # 2 presented the control solutions and a control test log with a notation that controls were performed on 11/18/2014. Observation of the control solutions revealed the low and normal control solutions were out of date. Observation revealed the low control solution expired 6/2012 (2 years, 4 months ago) and the normal control bottle expired 7/2014 (3 months ago). Further interview with AS #2 confirmed the low and normal control solutions were out of date and should not be used. Interview revealed after surveyor finding of no controls, staff performed quality controls checks with expired control solutions on November 18,2014. Interview revealed the control solution was not available and no testing had been done prior to November 18, 2014.

Interview with AS #2 on 11/21/2014 at 1220 revealed new control solutions had been ordered on 11/19/2014 but had not arrived.

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