HospitalInspections.org

Based on policy and procedure review, document review, interview and medical record review, the hospital does not maintain facilities and equipment to ensure an acceptable level of safety and quality; specifically:
1) There is not evidence that staff are cleaning the glucometer after each use.
2) The main hospital building and piped medical gas are not maintained at an acceptable level of safety and quality.

Findings include:

Finding #1:
Review on 07/08/14 of policy "Bedside Glucose Monitoring" (last revised 05/2013) revealed that cleaning of the (glucose) meter will be done after each use and will be documented once during the shift.

Review on 07/08/14 at 10:43 AM of the Intensive Care Unit "Glucometer, Temperature, Humidity and Cleaning Log" for July 2014, located at the nurse's station, revealed that the following entries for cleaning the glucometer each shift were blank:
- On 07/01/14: 7-3 and 11-7 shifts.
- On 07/02/14: 7-3, 3-11 and 11-7 shifts.
- On 07/03/14: 7-3 and 11-7 shifts.
- On 07/04/14: 3-11 and 11-7 shifts.
- On 07/05/14: 3-11 shift.
- On 07/06/14: 7-3 shift.
- On 07/07/14: 3-11 shift.
- On 07/08/14: 3-11 and 11-7 shifts.

During interview on 07/08/14, Director of Quality Management Staff #2 verified that staff are not completing the glucometer log each shift after use of the glucometer.

Medical record review on 07/11/14 revealed no evidence to indicate the glucometer was cleaned after each use for the following patients:
- Patient #1: Blood glucose finger sticks were obtained on 07/05/14 at 16:37 and 21:00 during the 3-11 shift, on 07/06/14 at 11:05 during the 7-3 shift, and on 07/07/14 at 16:29 and 19:42 during the 3-11 shift.
- Patient #7: Blood glucose finger sticks were obtained on 07/05/14 at 17:40 during the 3-11 shift, on 07/06/14 at 11:29 and 12:07 during the 7-3 shift, and on 07/07/14 at 17:32 during the 3-11 shift.

Finding #2:
Observation during tour of the emergency department (ED) on 07/08/14 revealed:
- In Bay #1 of the Fast Track area, the sink trap was leaking, with water pooled on the floor and water infiltrating behind the cove molding.
- In the area where portable x-rays are stored in the ED, there were multiple holes in the drywall.
- In the code room, the eight-door cabinet was missing two pieces of cove molding, each approximately one foot in length.
- In the soiled hold room, the exhaust diffuser was heavily dust loaded.
These findings were verified with Director of Emergency Services Staff #13 on 07/08/14.

Observation during tour of the Intensive Care Unit on 07/08/14 revealed:
- The exhaust diffuser at the nurse's station, by the printer, was heavily dust loaded.
- In the soiled hold room, some pieces of cove molding by the clinical sink were pulling away from the base, and some cove molding pieces were missing.
These findings were verified with Staff #2 on 07/08/14.

Observation during tour of the gastroenterology suite on 07/10/14 revealed:
- The exhausts in the visitor's restroom and the two restrooms in the suite were not functioning.
This finding was verified with Staff #2 on 07/10/14.

Observation during tour of the labor and delivery suite on 07/10/14 revealed:
- The exhaust in the restroom across from room #200 was not functioning.
This finding was verified with Staff #2 on 07/10/14.

Review on 07/14/14 of the medical gas report, completed by G. Riccelli of Medical Gas Technology on 04/28/13, revealed the following deficiencies were documented in the report:
- OR #5 Ceiling Oxygen - dynamic pressure low
- OR #5 Ceiling Nitrous Oxide - dynamic pressure low
- OR #5 Left Wall Vacuum - no vacuum flow
- OR #8 Ceiling Vacuum - no vacuum flow
- OR #8 Left Wall Vacuum - low flow
- Urology Room 1 Vacuum - vacuum leaks
- Nursery Left Oxygen - outlet leaks
- Room 423 Oxygen - outlet leaks
- Room 434 Vacuum - outlet leaks
- Room 436 Oxygen - outlet leaks
- Room 436 Vacuum - outlet leaks
- Room 438 Oxygen - outlet leaks
- Room 446 Oxygen - outlet leaks
- The dew point maximum upper limit for the medical air compressor was set higher than 39 degrees F.
There was no evidence provided by the hospital that these deficiencies were addressed. This finding was verified with Staff #2 on 07/14/14.