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A. Based on document review and interview, it was determined that for 2 of 2 (Pt #1 and Pt #2) patients on the 3 East Medical Unit (3 East) with indwelling urinary catheters (Foleys), the Hospital failed to ensure there were physicians' orders for the catheters; documentation of the date and time of Foley insertion; and the ongoing need for the catheters were reviewed daily to ensure removal of the Foleys as soon as possible.

Findings include:

1. The Hospital's policy titled, "Indwelling Foley Catheterization" (revised 06/2006) was reviewed on 6/6/18 and required, "...A physician order must be obtained before catheterization is done..."

2. The Daily Surveillance - Prevention of CAUTI's (Catheter Acquired Urinary Tract Infections) sheet, dated 6/5/18, was reviewed on 6/5/18 at approximately 1:00 PM and lacked documentation of the indication and ongoing need for the Foleys for Pt #1 and Pt #2.

3. The clinical record for Pt #1 was reviewed on 6/5/18 at approximately 11:30 AM. Pt #1 was a 94 year old female, admitted on 5/31/18, with diagnoses of hematuria (blood in the urine) and altered mental status. The physician's order, dated 6/1/18, included, "Insert Foley Catheter". The order did not include the indication for the Foley. Pt #1's daily assessment, dated and timed 6/2/18 at 8:58 PM, included, "Uninary Elimination: Continent; Urine Appearance: Clear; Urine Color: Yellow to Amber." Pt #1's daily assessments, dated and timed 6/3/18 at 7:00 AM and 6/4/18 at 8:00 PM, included, "Urinary Devices: Foley Catheter; Urine Appearance: Clear; Urine color: Yellow to Amber." The nurses' notes did not include documentation of the Foley insertion date and time, or the indication for the catheter insertion. Pt #1's clinical record also lacked documentation of the review of the continuing need for the catheter to ensure catheter removal at the earliest time indicated.

4. The clinical record for Pt #2 was reviewed on 6/5/18 at approximately 11:40 AM. Pt #2 was a 77 year old female, admitted on 6/5/18, with a diagnosis of altered mental status. The nurse's progress note on admission, at 6:19 AM, included, "A 77 year old female was brought into the unit from the ER [emergency room]...Pt is ambulatory with assist, incontinent of bladder (has foley)..." The Emergency Room Report Form, dated 6/5/18, lacked documentation of the insertion or presence of a Foley catheter in Pt #2 at the time of transfer from the ER to Pt #2's admission on 3 East. Pt #2's clinical record lacked a physician's order for a Foley. Pt #2's clinical record lacked documentation of the review of the need for the catheter to ensure catheter removal at the earliest time indicated.

5. On 6/5/18 at approximately 11:50 AM, an interview was conducted with the Registered Nurse (RN) (E #6) who was assigned to both Pt #1 and Pt #2 on 6/5/18 from 7:00 AM-3:00 PM. E #6 stated that he did not know why Pt #1 or Pt #2 had Foley catheters. E #6 stated that the need for catheters was not reviewed during shift report from previous shift RN. E #6 stated that he did not know the Foley insertion date, time, or person who inserted the Foley for Pt #1 or Pt #2.

6. During an interview with the Infection Control Nurse (E #3) on 6/5/18 at approximately 12:00 PM, E #3 stated that there should be a physician's order for a Foley, and the indication for continued need for the Foley should be documented and reviewed daily.

B. Based on document review, observation, and interview, it was determined that for 2 of 2 (E #4 and E #5) staff observed performing point-of-care blood glucose testing, the Hospital failed to ensure the the blood glucose meters were cleaned and disinfected after every use.

Findings include:

1. On 6/5/18 at approximately 2:25 PM, the Hospital's policy titled, "Bedside Blood Glucose Precision Xceed Pro Blood Glucose and Ketone Monitoring" (revised 12/2013) was reviewed and required, "...Whenever contaminated the glucometer is to be cleaned with an antiseptic wipe...Between patients the glucometer meter is to be cleaned with an antiseptic wipe..."

2. On 6/5/18 between approximately 11:00 AM and 11:30 AM, tours were conducted of the 3 South Medical Unit and the 3 East Medical Unit. At 11:00 AM, on the 3 South Medical Unit, E #4 (RN-Registered Nurse) was observed checking the blood sugar of Pt #3. Pt #3 was a 72 year old male, admitted on 6/2/18, with diagnoses of acute asthma and hyperglycemia due to diabetes melitus. After using the glucometer to check Pt #3's blood sugar, E #2 returned the glucometer to its storage case, which holds the glucometer and other testing supplies, without disinfecting the glucometer. E #2 then returned the storage case to the nurses' station where the glucometer was available for use on other patients. At 11:10 AM, on the 3 East Medical Unit, E #5 (RN) was observed checking the blood sugar of Pt #4. Pt #4 was a 78 year old male, admitted on 5/31/18 with diagnoses of aggressive behavior and right knee pain. After using the glucometer to check Pt #4's blood suger, E #5 failed to disinfect the glucometer prior to returning it to its storage case.

3. On 6/5/18 at approximately 11:20 AM, an interview was conducted with the Infection Control Nurse (E #3). E #3 stated that the glucometers should have been disinfected after use and before returning the glucometers to their storage cases.