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Based on review of medical records (MR) and interview it was determined the facility failed to ensure a patient received insulin as ordered for an elevated blood sugar and failed to provide teaching to a patient as ordered prior to discharge. This affected MR # 13 and had the potential to affect all patients served by the facility.

Findings include:

1. MR # 18 was admitted to the hospital 1/2/12 with diagnoses of Dyspnea, Pneumonia, Heart Failure and Diabetes Mellitus.

The patient had an order for sliding scale insulin before meals and at bedtime as follows:
150-200 Blood Sugar (BS)- 4 units Humulin R (regular)/ Novolin R Subcutaneously
201-250 Blood Sugar- 6 units Humulin R/ Novolin R Subcutaneously
251-300 Blood Sugar- 8 units Humulin R/ Novolin R Subcutaneously
301-350 Blood Sugar- 12 units Humulin R/ Novolin R Subcutaneously
351-400 Blood Sugar- 16 units Humulin R/ Novolin R Subcutaneously
Blood Sugar > (greater than) 400-20 units Humulin R/ Novolin R Subcutaneously. Recheck BS in one hour. If after one hour BS is >350 call the physician.

The blood sugar on 1/2/12 was recorded at 2100 (9:00 PM) on the Medication Administration Record as 547.

The nurses progress note dated 1/2/12 had documented at 2245 (10:45 PM), " Pt's (patient's) blood sugar was 547. Pt refused insulin due to nite (night) BS medication. Pt stated the medication with insulin 'bottoms her BS out'."

The nurse failed to notify the physician of the patient refusing the insulin for the elevated blood sugar and failed to recheck the blood sugar as directed by the sliding scale.

A physician's order was present in the medical record dated 1/4/12 at 2:00 PM to discharge the patient home with home health services. A second order was written by the physician 1/4/12 at 2:00 PM, " Nursing please instruct pt how to give herself insulin prior to discharge."

The only documentation on the nurses progress notes was at 7:45 AM. There was no documentation regarding discharge or teaching to the patient on the proper technique to prepare and administer her insulin.

In an interview with Employee Identifier # 4, Director of Nursing, on 4/4/12 at 2:00 PM, EI # 4 confirmed there was no documentation of the physician being notified of the patient refusing insulin and no documentation the patient was instructed in the proper technique to prepare and administer insulin.

Based on observation, review of facility policy and staff interview, it was determined the facility failed to ensure the staff followed its policy for Intravenous (IV) Therapy during 1 of 3 observations for IV medication administration. This affected Medical Record (MR) # 8 and had the potential to affect all patients receiving Intravenous therapy at the facility.

Findings include:


Facility Policies/Procedures Number 3101-182
Date Effective: 5/2009 Revised
Title: Intravenous (IV) Therapy: Adult-Pediatric
(Insertion, care of, PRN ( as needed ) Adaptor, Removal and Complications of Peripheral IV's )

Procedure...

Flushing Peripheral IV's/PRN Adaptors:
1. Gather supplies (syringes of flush solutions, alcohol solutions, alcohol preps, and medication to be administered if indicated).
2. Verify placement and patency of the vascular access device.
3. Flush the catheter with 1-2 ml (milliliter) of normal saline (NS) (or quantity sufficient to clear any visible blood from the line) using positive pressure, a pulsating flush and clamping the tubing while maintaining forward pressure to prevent reflux and occlusion.
4. Administer medication when indicated.
5. Repeat flush procedure following medication administration.
6. Document procedure and condition of site...


1. MR # 8 was admitted to the facility on 4/2/12 with diagnoses including chest pain and Atrial fibrillation with rapid ventricular response.

Review of the M.A.R. (Medication Administration Record) dated 4/4/12 revealed physician's orders for medications including Zofran 4 mg (milligram) IV every 6 hours prn n/v ( nausea and or vomiting).

During medication passes in the Intensive Care Unit (ICU) on 4/4/12 at 9:15 AM, the surveyor accompanied Employee Identifier (EI) # 6, ICU Registered Nurse (RN). After entering the patient's room, EI # 6 found the patient experiencing dry heaves and determined it was appropriate to administer the prn Zofran via the patient's peripheral IV/PRN adaptor.

At 9:25 AM, the surveyor observed EI # 6 administer Zofran 4 mg IV (slow IV push) via the peripheral IV/PRN adaptor. EI # 6 then flushed the IV/PRN adaptor with 10 ml's of NS.

EI # 6 failed to flush the IV/PRN adaptor with 1-2 ml's of NS or quantity sufficient prior to administering IV medications.

An interview was conducted on 4/4/12 at 3:40 PM with EI # 4, Director of Nursing, who was present during the medication pass. EI #4 reported he/she did not see the above observation and validated the facility's policy of NS flush prior to IV medication administration.

Based on observations, review of the dietary policies and staff interview, it was determined the facility failed to ensure the staff followed their policy for the manual cleaning and sanitizing of the 3 compartment sink for 2 of 2 months reviewed. This had the potential to negatively affect all patients, staff and visitors who consumed foods prepared at the facility.

Findings include:

Facility Policy 500-003
Subject: Manual Cleaning and Sanitizing (Pot and Sink)
Revised September 2004

"Procedure....
5. *Sanitize in third compartment by submerging utensils under water with Mikro-quat-K Sanitizer for one minutes (minute). (slowly count to 60).
*Record P.P.M.s (parts per million) of sanitizer a.m. and p.m. on sheet provided.
*Press automatic dispenser one time.
*If not 60 P.P.M.s push button again and recheck with test strip.
*If automatic dispenser does not work, put 1/4 Mikro-quat-K in third compartment sink (this was as it was written in the policy). Then check again using test strips. Must be 50 P.P.M.s or higher....."

A tour of the kitchen was conducted on 4/3/12 at 10:05 AM. The surveyor observed the kitchen was equipped with a 3 compartment sink. The surveyor observed the name on the bottle of strips that was to be used to check the 3 compartment sink was QAC QR Test Strips from Ecolab. The label on these strips did not have an indicator for P.P.M. below 100 and could not be used to make sure the P.P.M. was not less than 50 as indicated in the policy.

The surveyor observed the sanitizer used was labeled Ecolab Oasis 146 Multi Quat Sanitizer and was not the Mikro-quat-K sanitizer documented in the policy.

On 4/3/12 at 10:15 AM, the surveyor observed the Pot Sink Temperature
log sheet. Review of the Pot Sink Temperature log sheet revealed the following documentation in parenthesis beneath the title, "If no 50 ppm (parts per million) please notify maintenance or supervisor....Starting October 13, 2000 please record parts per million by looking at test strip container and record. Be sure to initial who records". Review of the
log sheet for April 2012 did not have the P.P.M.s documented for the AM or PM for 4/1/12, 4/2/12 or for the AM on 4/3/12 and the dates were not initialed by a staff member. Review of the Pot Sink Temperature log sheet for March revealed documentation the pot sink was checked on March 2, 2012 in the AM and was 200 P.P.M. There was no documentation the pot sink was checked on any other days in March 2012

An interview conducted on 4/3/12 at 10:20 AM with Employee Identifier (EI) # 3, Dietary Manager, and EI # 7, Registered Dietician, confirmed the aforementioned findings.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on observation, review of the Centers for Disease Control (CDC) and Prevention best practices, policy review and staff interview, it was determined the facility failed to ensure the infection control policy for the cleaning of blood glucose meters followed the CDC and Prevention best practices guidelines and failed to ensure the staff followed its policy for hand hygiene after blood glucose monitoring during 1 of 1 observations of blood glucose monitoring. This had the potential to affect all patients served at the facility and employees of the facility.

Findings include:

Facility Policy No. 5602-2225
Revised 12/2007
Title: Hand Hygiene.....

Policy
1. Hand hygiene will be performed at the following times.....

Before and after contact with each patient, his environment, and things that come in contact with the patient.....

Facility Policy No. 3101-036
Approved 9/2011
Title: Accu-Chek Inform System....
Patient Preparation
.....The Operator's hands must be washed before and after testing......

Patient Testing
Policy....
Procedure.....
14. Remove gloves and dispose of them according to your facility's infection control policy. Wash hands thoroughly with soap and water....

Storage/Maintenance of the Accu-Chek Inform System
Policy.....
Cleaning and maintenance of the Accu-Chek Inform System is performed at the following time(s):
Monthly or when ever the Accu-Check Inform appears visibly contaminated with blood....

Infection Control Guidelines
Policy.....
Gloves are to be removed and hands washed thoroughly with soap and water after completing the test procedure and prior to handling equipment not related to the procedure. ....
The Accu-Chek Inform meter will be disinfected if contaminated with blood....


Centers for Disease Control and Prevention
January 4, 2012
"Infection Prevention during Blood Glucose Monitoring and Insulin Administration

? FAQs: Blood Glucose Monitoring and Insulin Administration ..........

The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting hepatitis B virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration.

CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements:.....
? Fingerstick devices should never be used for more than one person
? Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer ' s instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared .... "

On 4/3/12 at 10:45 AM the surveyor observed Employee Identifier (EI) # 1, Registered Nurse (RN)/Operating Room Manager, check the blood glucose of an unsampled patient, Patient Identifier # 1, with the Accu-Chek Inform meter (blood glucose monitoring machine). EI # 1 removed his/her gloves after checking the patient's blood glucose but did not wash his/her hands per policy before making a telephone call to the surgery suite.

EI # 1 did not clean the Accu-Chek Inform meter according to CDC guidelines prior to putting it into the Accu-Chek carrying case. EI # 1 placed the Accu-Chek carrying case on the patient's stretcher and transported PI # 1 to the surgery suite where the Accu-Chek Inform meter was taken out of the carrying case and was placed on the Accu-Check Inform docking station.

During an interview on 4/3/12 at 11:45 AM, EI # 1 confirmed the staff does not clean the surface of the Accu-Chek Inform machine between patient's use.

During an interview on 4/4/12 at 9:30 AM, EI # 2, RN/Quality Coordinator, confirmed that after performing an Accu-Chek the staff should remove gloves and clean hands with soap and water or with the sanitizer.

During an interview on 4/4/12 at 9:55 AM, EI # 2 confirmed their policy was that the Accu-Chek Inform machine was to be cleaned once a month.

Based on observations, review of surgery policies and procedures, and staff interview, it was determined the facility failed to have a policy to assure the operating rooms (ORs) were monitored for safe parameters of humidity and temperature for 2 of the hospital's 2 operating rooms. This had the potential to affect all patients served by the facility.

Findings include:

A tour of the surgical department was conducted on 4/3/12 at 11:00 AM with Employee Identifier (EI) # 1, Registered Nurse (RN)/OR Manager. During the tour the surveyor observed there were two ORs.

During an interview on 4/3/12 at 1:40 PM, the surveyor requested to see the temperature and humidity monitoring logs for the two ORs. EI # 1 stated that there was no documentation the humidity and temperature of the ORs were being monitored. EI # 1 further stated that there was no policy regarding the monitoring of the ORs temperature and humidity.

Based on review of the operating room (OR) register and staff interview, it was determined the facility failed to ensure the OR register for 3 of 3 months reviewed contained documentation of the inclusive or total time of the surgeries. This had the potential to affect all patients requiring surgical services at the facility.

Findings include:

On 4/3/12 at 12:55 PM, the surveyor reviewed the surgery register for January 2012 through March 2012. The surgery register did not contain documentation of the total time of the surgery for any of the surgeries performed from January 2012 through March 2012.

An interview on 4/3/12 at 1:40 PM with Employee Identifier # 1, Registered Nurse/OR Manager, confirmed the aforementioned findings.