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Based on observation, interview and facility policy and procedure review, it was confirmed that the facility failed to monitor implementation of infection control measures related to hospital personnel.

Findings:

Observation on 3/22/2016 at 11:50 AM revealed Staff A, a Certified Nursing Assistant (CNA), approached the patient in room 2224-B to do a blood sugar check. CNA removed the Exceed PRO/ Glucometer equipment from case, got an alcohol swab and a gauze and proceeded to enter the patients ' room. CNA left the equipment case outside the patients ' room. CNA donned a pair of gloves. CNA used alcohol swab and wiped the patients ' right middle finger and air dried. A needle stick was done and obtained a drop of blood on a test strip. Obtained a blood sugar (BS) reading of 290 mg/dl. CNA removed gloves, carried the Exceed PRO / Glucometer and exited the patients ' room at 11:53 AM. Did not observe the CNA washed hands or used a hand sanitizer. Did not observe the CNA sanitized the Exceed PRO/ Glucometer.

Staff A exited 224-B at 11:53 AM and proceeded to perform another blood sugar check in room 2228.

Observation on 3/22/2016 at 11:55 AM revealed Staff A, same CNA entered room 2228 with same Exceed PRO/Glucometer on hand. CNA explained to Patient that she will check his blood sugar. Did not observe the CNA clean or disinfect the Exceed PRO before using it to the next patient. CNA donned a pair of gloves. Identified the patient using the exceed PRO scanner. Placed a paper barrier on bedside table and placed all the blood sugar supplies. CNA cleansed the right forefinger with alcohol, did a needle stick, collected a drop of blood on a test strip and obtained a BS of 386 mg/dl. CNA applied gauze on to needle stick site. CNA removed gloves and exited room at 11:58 AM. Did not observe the CNA wash her hands and did not observe the CNA disinfect the exceed PRO equipment for the second time. CNA placed the glucometer back to its ' charging base at the nurses ' station at 11:59 AM.

during an interview on 03/22/16 at 11:59 AM, Staff A, CNA, stated she worked here for 6 months. CNA stated that she had training on the use of exceed PRO / glucometer during orientation. When asked how often does she cleanse the equipment, she replied; " oh, I forgot, I should have cleaned it after each patient use, I should have known better " . This CNA confirmed that she failed to cleanse and disinfect the exceed PRO/glucometer equipment after each patient use.

During an interview on 03/22/16 at 12:01 PM, Director of Quality,interviewed the CNA, Staff A, the director of Quality asked staff A, when should she clean the blood glucose equipment, CNA replied after each patient use. What do you use to clean the equipment with, she replied with the purple wipes.

During an interview on 03/22/16 at 2:35 PM,with Staff I, Registered Nurse (RN) stated she worked here for the past 10 years. When asked on the facilities policy on Glucometer care, RN replied; we clean it every after patient use.

record review of the facility's policy " handwashing" dated 05/15, showed the hospital personnel are to decontaminate their hands:
A. Before having direct contact with patients.
B. Before donning sterile gloves.
F. After contact with inanimate objects including medical equipment in the immediate vicinity of the patient.
G. After removing gloves.
The use of alcohol-based hand rub is microbiologically effective and less time consuming than standard hand washing. Alcohol based antiseptics (Cal-Stat) will be utilized before and after patient contact, and in between the standard hand washing practices with running water.

During an interview on 3/22/2016 at 1:15 PM , Infection Control Practitioner, states that the definition of decontaminate is washing hands with soap and water and or use of hand gel.

Review of the facility ' s policy on Cleaning, Disinfection and Sterilization of Patient Care Items Policy with an effective date of 09/91 and reviewed on 2/12/2015 revealed Classification of Items:
A. Determining the appropriate category under which a patient item is to be cleaned, disinfected or sterilized depends upon the intended use of that particular item and the manufacturer ' s recommendations.
Classification are:
1. Critical items
2. Semi-critical items (Class II) - include any instrument that will come in contact with intact mucous membranes, but does not penetrate body surfaces.
3. Noncritical items (Class III) - include equipment that comes in contact with patients and their intact skin. Examples are blood pressure cuffs, stethoscopes, walkers, and wheelchairs. Routine cleaning and disinfection with a hospital approved product is sufficient to reduce the number of micro-organisms on the surface of a non- critical items. Alcohol may also be used to clean non - critical items provided they are not visibly soiled.

The policy titled " Cleaning, Disinfection and Sterilization of Patient Care items" revised 02/12/15 states that Electronic equipment- Glucometers, I-stats are wiped down after each patient use.

During an interview on 3/22/2016 at 1:15 PM, Infection Control Practitioner, RN, on stated that the Glucometer equipment/ Exceed PRO falls under non-critical items.