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A. Based on observation and review of the facility's policies and procedures, it was determined that the facility failed to ensure that the policy and procedure for the insertion of an arterial line was followed.

Findings include:

Reference: Facility policy titled, "Arterial Line Insertion, Assisting In" states, "Equipment: Sterile gloves for the provider; un-sterile gloves for RN...Procedure: 3. Perform hand hygiene, don gloves and goggles..."

On 8/15/12, Patient #1 was observed in the Operating Room being prepared for an Aortic Valve Repair (AVR). Prior to the surgical procedure, at 1:45 PM, Staff #15 was observed prepping the right wrist of Patient #1 in an attempt to insert an arterial line. Staff #15 wiped the right wrist with chlorhexidine gluconate (CHG) skin antiseptic and proceeded to touch the area with an ungloved finger. Staff #15 was unable to insert the arterial line in the right wrist. At 1:50 PM, the same staff member (Staff #15) moved to the opposite side of the patient, cleansed the left wrist with CHG skin antiseptic and touched the left wrist with an ungloved finger. Staff #15 failed to don sterile gloves prior to the insertion of the arterial line, as indicated in the above referenced policy.


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B. Based on observation, staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure implementation of its policy for Blood Glucose Monitoring.

Findings include:

Reference: Facility policy titled, "Point of Care (POC) Blood Glucose Monitoring" states "Procedure ... 14. Cleanse the selected site with alcohol and allow drying. ... Infection Prevention and Control: ... [5 th bullet] Blood glucose meter should be wiped down after each patient using approved hospital germicidal surface wipes."

1. On 8/14/12 at 11:15 AM Unit 4 Lesser was toured in the presence of Staff #2 and Staff #3. Staff #9 was observed performing bedside blood glucose (BBG) monitoring on Patient # 3, and then Patient #4.

a. Prior to performing the BBG on Patient #3, Staff #9 was completing a BBG on another patient. He/she finished, used alcohol based hand sanitizer to clean his/her hands, and then proceeded into the room of Patient #3 to perform the BBG. Staff #9 did not wipe the glucometer machine after completing the BBG of the patient prior to Patient #3. Staff #9 confirmed that he/she did not clean the machine earlier prior to this patient, and after the first patient.

b. Staff #9 was observed performing BBG on Patient #3. Staff #9 used an alcohol pad to clean the glucometer machine after completion of the BBG on Patient #3 instead of hospital approved disinfectant wipes.

c. Staff #9 was observed performing BBG on Patient #4. Staff #9 cleaned the finger of Patient #4 with an alcohol pad, then wiped his/her finger dry with a non-sterile (clean) gauze pad. Staff #9 did not allow the finger of Patient #4 to dry after cleaning it with the alcohol pad, as indicated in the above referenced policy.