HospitalInspections.org

The facility's governing body failed to ensure patient care was provided in accordance with the facility policy and medical records were completed, accurately witten, promptly completed and ensured the integrity of the authetication of the author of each entry in that:

1. Cleaning and disinfection of equipment used on patients were properly cleaned and disinfected prior to returning to a clean area in 1 of 6 blood glucose glucometers observed. The facility has 10 current diabetic patients requiring multiple glucose testing daily exposing the patients to risk of infection and spread of disease which can result in actual harm to patients.

2. Failed to ensure that glucose meters were tested daily using the control solutions to ensure to ensure glucometer were within range and documented on the Glucometer QC (quality control) Log.

3. Failed to ensure emergency supply cart and equipment were check daily and documented on the emergency Medical Equipment Daily Check form.

4. Failed to ensure records were completed, signatures were legible and included the required completed signatures with title, date and time and signatures were autheticated by the author of each entry.

Policies Reviewed:

Review on 08/17/2022 of the facility's current Infection Control Policy and Procedures titled, "Hospital Equipment Cleaning", Date reviewed 05/17/2022, approved by Board of Governors. Purpose: To maintain a clean environment and reduce the possibility of cross-contamination between patients. Policy: 3. Equipment used routinely during the day shall be cleansed after each use per national healthcare regulatory standards. When none are specified, patient equipment will be cleaned per the manufacturer's instructions or with and EPA approved hospital germicidal wipe/disinfection. Example of these are...b. Blood Glucose machines.

Review on 08/17/2022 of the facility's current policies and procedures titled, "Glucose Monitoring", Date reviewed 08/10/2022, Approved by Board of Governors. Policy: Diabetic patients will be monitored according to physician orders. In-house Glucose Monitoring should be completed as a waived test. Procedure: 4. Glucometer machine will be kept on the unit in the Medication Room for patient use. 5. Daily the glucometer will be checked by the Night shift by using the control solution obtained from the manufacturer....Compare meter result to Control Test range printed on test strip via label for level of control solution you are using. If result is in range, System can be used for testing blood. If results do not fall within range, repeat test using a new test strip. 7. Document the test level 1 and test level 3 on the Glucometer QC Log. Should the reading fall outside of the normal parameters identified on the test strip bottle, do not use the glucometer, and report the glucometer malfunction to the house supervisor to be serviced or replaced. 9. The Glucometer machine will be cleaned between patient used with PDI Super Santi wipes.

Review of the facility's Emergency Medical Equipment Daily Checklist on 08/17/2022 reads:

I. Emergency supplies initials indicate that all Emergency Supplies and medications are present, tear away locks are intact, no rips or tears are noted to emergency supply packaging and expiration dates are check ad "in date" if not replace and/or notify the Nursing Supervisor.

II. Emergency Equipment AED* (Check each element as indicated and mark as a check mark if test is positive and enter initials when complete. (If AED fails test, see instructions below).

III. Oxygen Tank**(Enter Oxygen Level in the spaces provided and enter initials when completed. (If oxygen level is below 50%, see instructions below)

*If AED does not turn on/off Immediately notify Facilities at 253-651-6529 and notify the nursing Supervisor
** If O2 tank is below 50% Immediately notify Facilities at 253-651-6529 and notify the nursing Supervisor.

Review of the facility's current policy issued by Medical Records and approved by the Board of Governors titled "Documentation in the Patient's Medical Record", Date of Revised 06/26/2015, Date Reviewed 05/17/2022. Documentation in the Medical Record: Purpose: To standardize the procedures for routine documentation in the patient records. Policy: It is the policy of the Behavioral Hospital of Bellaire (Behavioral Hospital of Bellaire) to establish standards for routine documentation within the patient medical record. These standards are outlined in the following table and shall be followed by all - Behavioral Hospital of Bellaire employees when documenting in the patient's medical record.

Chart Notes - All contacts with the patient must be documented with a signature, date and time.

Signatures should be legible (fairly consistent) with minimally first initial, full last name and title. Unacceptable - illegible signatures, initials only, last name only, no title following signature.

Forms: All blanks on forms should be completed (unknown, negative, not obtained, N/A, ECT.) Unacceptable - leaving blanks on forms empty, using unapproved forms in the medical record.

Legibility: Attempt to write legible. Medical records should be made in a clear and concise language. Only use abbreviations approved by the medical staff. Unacceptable - using unapproved abbreviations.

Findings:

Observation on 08/16/2022 at 1145 of Unit #4 medication room along with registered nurse (RN) (ID #M) the handheld glucose monitor was observed to have a red colored droplet and smear on the front surface of the glucose monitor along with a red colored smear on the back surface of the glucose monitor. Glucometer was observed to be a HEB in control True Metrix Glucose Monitor (SN # T02949526). Manufactures guidelines limit this glucometer model for single patient use only and not to be shared between patients. Unit 4 current has four diabetic patients requiring blood glucose testing.

Interview on 08/16/2022 with staff (ID #M) confirmed that Unit #4 currently has diabetic patients maybe three or four that require blood glucose finger sticks and the patients' blood is tested using this glucometer. Staff (ID #M) confirmed she had used the glucose monitor identified as a HEB in Control True Metrix Glucose Monitor, serial # T02949526 earlier to check patients' blood sugars on the unit. Staff (ID #M) confirmed, and she had wiped down and disinfected the glucometer after each use with a Sani-Cloth disinfecting wipes before returning it to the clean area. Staff (ID #M) confirmed the meter was used on multiple patients on the unit and had disinfected the glucometer and the meter was ready to be used. Surveyor pointed out the reddish droplet and smear on the glucose monitor to Staff (ID #M) who verified the red droplet and smear on the glucometer.

Observation on 08/16/2022 at 1210 of Unit #4 along with employee (ID #B) the form titled "Emergency Medical Equipment Daily Checklist" for August 2022 daily checks were not completed for 1 of 16 days (August 5, 2022) for August 2022.

Employee (ID #B) confirmed the Emergency Medical Daily Check did not have any documentation that the Emergency Medical Equipment Daily Checklist was completed for August 5, 2022.

Observation on 08/16/2022 at 1615 of Unit #8 medication room along with Chief Nursing Officer, staff (ID #D) and registered nurse, staff (ID #O) the surveyor observed 1 glucose meter located in the medication room identified as a True Metrix Pro Glucometer. Manufactures guidelines allow for shared patient use with proper cleaning and disinfection between patient use with this meter. Unit 8 currently has one diabetic requiring blood glucose testing

Interview with staff registered nurse (ID#O) as asked how she cleans and disinfects the glucometer. Staff (ID #O) replied she cleans the glucometer with alcohol swabs between patients, and at the start and end of the day she disinfects with Super Sani-cloth.

Interview with Staff (ID #D) stated that staff know how to disinfect meters and Sani-Cloth disinfecting wipes should be used, not alcohol.

Documents Reviewed:

Review of the facility's Glucometer Control log for August 2022 fourteen entries were documented on the form column titled "RN Legible Signatures", for August 1 through the 14th. All documented signatures (4) were illegible along and nine documented what appeared to be just initials.

Medical Record Reviewed:

Patient (ID #1) medical records reviewed:

8/3/2022 - 7a-7p - Patient Medical Assessment signed by Staff (ID #W) with first name only followed by LVN (licensed vocational nurse) no last name documented.

8/3/2022 - 7a-7p - Treatment Plan Progress Note Psychiatric signed by Staff (ID #W) with first name only followed by LVN (licensed vocational nurse) no last name documented, no date and time of entry.

8/2/2022 - Multidisciplinary Progress signed by Staff (ID #X) with no title following signature.

8/3/2022 - Multidisciplinary Progress signed by illegible signature.

8/8/2022 - Progress Note- electronically signed by on 8/06/22 by NP staff (ID #G) (Nurse Practitioner). Electronically signed by physician staff (ID #H) on 8/08/22. Physician denies he signed his electronic signature.

Patient (ID #2)

8/11/2022 - High Risk Notification Alert signed by staff (ID #K) with first name and last initial only along with title.

8/11/2022 - Level of Care Recommendation Form signed by staff (ID #K) with first name and last initial only and no title.

8/11/2022 - Psychiatric SBAR - Intake to unit Patient Report Worksheet signed by staff (ID #K) with first name and last initial only along with title.

8/11/2022 - Report of Collateral Information signed by staff (ID #K) with first name and last initial

Patient (ID #3)

6/2022 - Report of Collateral Information signed by illegible signature documented title RN (registered nurse) legible.

Interview and record review with Director of HIM, Medical Records, staff (ID #J) on 08/16/2022 confirmed the above signature for patient (ID #2's) medical records were not acceptable. Staff (ID #J) confirmed the signatures should be legible and include the first initial, or first name along with the last name and the credentials of the persons signing the documents. Staff (ID #J) confirmed the hospital had identified some issues with signatures in medical records.

Interview on 8/16/2022 at 1550 with registered nurse, staff (ID #K) confirmed she signed the medical record documents as her first name and last name initial. Staff (ID #K) confirmed she always signs her name this way and was unaware that she needs to include her last name and her credentials with her signature.

Interview with Staff (ID #H) stated in an interview on 8/17/2022 that he was out of the country from 7/26/2022 through 8/11/2022 and never saw the patient (ID #1) or signed the progress note or authorized anyone to sign his electronic signature. Staff (ID #H) confirmed he does not know his electronic signature got on the document and you must use a code to sign electronic signature

.

Based on record review and interview the facility failed to inform patient (ID#1) guardian the results of her complaint/grievance.

Based on interview and record review the governing body did not ensure staff followed the policy regarding complaints and grievances and did not provide the patient family with written notice of its decision that contains the name of the hospital contact person, the steps taken to investigate her complaint.

Findings Include:

Record review of facility policy Patient & Family Complaints & Grievances, reviewed 05/17/22, that states "a grievance is defined as a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient care ( when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect ... ....related to rights and limitations provided by 42 CFR 489.

Interview with the patient advocate and court liaison on 08/18/2022 at 1121 with staff (ID#R) who stated:

When questioned about the situation still being open and reading the policy to her, staff (ID#R) stated "I did my part."

Based on observation, interview and record review the facility failed to ensure patients received care in a safe setting in that:

1. Cleaning and disinfection of equipment used on patients were properly cleaned and disinfected prior to returning to a clean area in 1 of 6 blood glucose glucometers observed. The facility has 10 current diabetic patients requiring multiple glucose testing daily exposing the patients to risk of infection and spread of disease which can result in actual harm to patients.

2. Failed to ensure that equipment designated by the manufacture as single patient use were not shared between multiple patients.

2. Failed to ensure that glucose meters were tested daily using the control solutions to ensure to ensure glucometer were within range and documented on the Glucometer QC (quality control) Log.

3. Failed to ensure emergency supply cart and equipment were check daily and documented on the emergency Medical Equipment Daily Check form.

Policy Reviewed:

Review on 08/17/2022 of the facility's current Infection Control Policy and Procedures titled, "Hospital Equipment Cleaning", Date reviewed 05/17/2022, approved by Board of Governors. Purpose: To maintain a clean environment and reduce the possibility of cross-contamination between patients. Policy: 3. Equipment used routinely during the day shall be cleansed after each use per national healthcare regulatory standards. When none are specified, patient equipment will be cleaned per the manufacturer's instructions or with and EPA approved hospital germicidal wipe/disinfection. Example of these are...b. Blood Glucose machines.

Review on 08/17/2022 of the facility's current policies and procedures titled, "Glucose Monitoring", Date reviewed 08/10/2022, Approved by Board of Governors. Policy: Diabetic patients will be monitored according to physician orders. In-house Glucose Monitoring should be completed as a waived test. Procedure: 4. Glucometer machine will be kept on the unit in the Medication Room for patient use. 5. Daily the glucometer will be checked by the Night shift by using the control solution obtained from the manufacturer....Compare meter result to Control Test range printed on test strip via label for level of control solution ou are using. If result is in range, System can be used for testing blood. If results do not fall within range, repeat test using a new test strip. 7. Document the test level 1 and test level 3 on the Glucometer QC Log. Should the reading fall outside of the normal parameters identified on the test strip bottle, do not use the glucometer, and report the glucometer malfunction to the house supervisor to be serviced or replaced. 9. The Glucometer machine will be cleaned between patient used with PDI Super Santi wipes.

Review of the facility's Emergency Medical Equipment Daily Checklist reads:

I. Emergency supplies initials indicate that all Emergency Supplies and medications are present, tear away locks are intact, no rips or tears are noted to emergency supply packaging and expiration dates are check ad "in date" if not replace and/or notify the Nursing Supervisor.

II. Emergency Equipment AED* (Check each element as indicated and mark as a check mark if test is positive and enter initials when complete. (If AED fails test, see instructions below)

III. Oxygen Tank**(Enter Oxygen Level in the spaces provided and enter initials when completed. (If oxygen level is below 50%, see instructions below)

*If AED does not turn on/off Immediately notify Facilities at 253-651-6529 and notify the nursing Supervisor
** If O2 tank is below 50% Immediately notify Facilities at 253-651-6529 and notify the nursing Supervisor

Findings:

Observation on 08/16/2022 at 1145 of Unit 4 medication room along with registered nurse (RN) ID #M the handheld glucose monitor was observed to have a red colored droplet and smear on the front surface of the glucose monitor along with a red colored smear on the back surface of the glucose monitor. Glucometer was observed to be a HEB in control True Metrix Glucose Monitor (SN # T02949526). Manufactures guidelines limit this glucometer model for single patient use only and not to be shared between patients.

Interview on 08/16/2022 with staff (ID #M) confirmed that Unit #4 currently has diabetic patients maybe three or four that require blood glucose finger sticks and the patients' blood is tested using this glucometer. Staff (ID #M) confirmed she had used the glucose monitor identified as a HEB in Control True Metrix Glucose Monitor, serial # T02949526 earlier to check patients' blood sugars on the unit. Staff (ID #M) confirmed and she had wiped down and disinfected the glucometer after each use with a Sani-Cloth disinfecting wipes before returning it to the clean area. Staff (ID #M) confirmed the meter was used on multiple patients on the unit and had disinfected the glucometer and the meter was ready to be used. Surveyor pointed out the reddish droplet and smear on the glucose monitor to Staff (ID #M) who verified the red droplet and smear on the glucometer.

Observation of the emergency crash cart on 08/16/2022 at 12:10 PM of Unit 4 along with employee (ID #2) the form titled "Emergency Medical Equipment Daily Checklist" for August 2022 daily checks were not completed for 1 of 16 days (August 5, 2022) for August 2022.

Employee (ID #2) confirmed the Emergency Medical Daily Check did not have any documentation that the Emergency Medical Equipment Daily Checklist was completed for August 5, 2022.

Observation on 08/16/2022 at 1615 of Unit 8 medication room along with Chief Nursing Officer, staff (ID #D) and registered nurse, staff (ID #O) the surveyor observed 1 glucose meter located in the medication room identified as a True Metrix Pro Glucometer. Manufactures guidelines allow for shared patient use with proper cleaning and disinfection between patient use with this meter.

Interview with staff registered nurse (ID#O) as asked how she cleans and disinfects the glucometer. Staff (ID #O) replied she cleans the glucometer with alcohol swabs between patients, and at the start and end of the day she disininfects with Super Sani-cloth.

Interview with Staff (ID #D) stated that staff know how to disinfect meters and Sani-Cloth disinfecting wipes should be used, not alcohol.

Observation on 08/16/2022 at 16:30 of Unit #5 along with Staff (ID #D) and registered nurse (ID #P) revealed one glucometer identified as a HEB in Control True Metrix Glucose Monitor. Unit #5 currently has a census of 3 diabetic patients. Manufactures guidelines limit this glucometer model for single patient use only and not to be shared between patients.

Observation of Unit #7 along with Staff (ID #D) and registered nurse Staff (ID #P) one glucometer was identified as a True Metrix Pro Glucometer. Manufactures guidelines allow for shared patient use with proper cleaning and disinfection between patient use with this meter. Observation of the facility's Glucose Control Log for Unit #7, August 2022 did not have documentation of glucometer control testing by a registered nurse for 08/15/2022.

Interview with staff (ID #P) confirmed the night nurse should of completed the glucometer control log ever for 08/15/2022 and confirmed it was not documented as done.

Based on review of documentation and interview it was determined that the facility failed to ensure that a 12 hour nursing assessment was completed by a Registered Nurse in 1 of 10 records reviewed.

Policy Reviewed:

Review on 08/18/2022 of the facility's current Policy titled "Patient Assessment Daily Nursing Flow Sheet", issued by Nursing, date revised 7/15/2019.

Policy: The Nursing Shift Progress and Assessment Note are utilized on all patients as a method of documentation and reassessment of the patient in order to communicate treatment provided and its results.

Purpose: To ensure an accurate and concise assessment and record of the patient's needs and treatment every shift. RN assessment will be completed at least every 12 hours.

Procedure: 1. The Nursing shift progress and assessment note is the primary documentation for nursing staff. The RN completes the nursing flow sheet each shift and documents a progress notes as described by 3.0. any positive finding require documentation.

Findings were:

A review of the medical record of patient (ID #10) on 08/16/2022 at 1130 long with Performance Improvement Director, staff (ID #B) and registered nurse staff (ID #M) revealed that the registered nurse assessments (required at least every 12 hour) were not completed for patient (ID #10) for 08/15/2022.

In an interview on 08/16/2022 with staff (ID #B) it was confirmed that the above referenced nursing assessments was not found documented in the patient (ID#10's) medical records. No additional information was received prior to exit.



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Based on record review and interview the facility did not ensure that nursing completed nursing assessment on one of one patient (ID#1) record.

Findings Include:

Record review of the facility policy "Patient Falls: Prevention and Management" reviewed 05/17/22 stated
#5. Post Fall Interventions: The RN will complete a post falls assessment including neuro status-for head injury initiate neuro checks every 4 hours x 24 hours
#6. Notification Post Fall: Staff shall hold an emergency treatment team meeting for multiple falls during hospitalization (e.g.: more than one fall even if they occur on different days).

Record review of the nursing revealed the patient fell out of bed on 07/31/2022 dated 7p-7a documented by staff nurse (ID#AA) who notified the medical provider (ID# BB).

Record review of progress notes dated 08/02/2022 at 1500 by NP (ID #X) who documented 07/31/2022 that patient (ID#1) was found on the floor of the shower and denied any head injury or lost of consciousness. Patient stated she slipped.

Record review of the medical record did not reveal any documentation of neuro vital signs or an indication an emergency treatment meeting had been scheduled to address patient (ID#1), fall(s).

Record review of the incident report dated 08/01/22 at 1454
revealed patient (ID#1) was sitting in a wheelchair in the hallway when another patient came up behind her and hit her in the head with her fist. Aggressive patient was moved away. Camera reviewed supported this incident.

Record review of the nursing progress notes dated 08/01/2022 revealed no documentation addressing the trauma to patient (ID#1) head.

Interview on 08/18/2022 at 1030 with Jonell Comegys staff (ID# E) Risk Mtg who verified the video of the altercation patient (ID#1) being hit by another patient.

The facility failed to ensure its policy for medical records was enforced in that medical records were found to be incompleted, accurately written, promptly completed and ensured the integrity of the authentication by ensuring the author of each entry shall be identified and shall authenticate the entry in 3 out of 10 records reviewed.

Policy Reviewed:

Review of the facility's current policy issued by Medical Records and approved by the Board of Governors titled "Documentation in the Patient's Medical Record", Date of Revised 06/26/2015, Date Reviewed 05/17/2022. Documentation in the Medical Record: Purpose: To standardize the procedures for routine documentation in the patient records. Policy: It is the policy of the Behavioral Hospital of Bellaire (Behavioral Hospital of Bellaire) to establish standards for routine documentation within the patient medical record. These standards are outlined in the following table and shall be followed by all - Behavioral Hospital of Bellaire employees when documenting in the patient's medical record.

Chart Notes - All contacts with the patient must be documented with a signature, date and time.

Signatures should be legible (fairly consistent) with minimally first initial, full last name and title. Unacceptable - illegible signatures, initials only, last name only, no title following signature.

Forms: All blanks on forms should be completed (unknown, negative, not obtained, N/A, ECT.) Unacceptable - leaving blanks on forms empty, using unapproved forms in the medical record.

Legibility: Attempt to write legible. Medical records should be made in a clear and concise language. Only use abbreviations approved by the medical staff.

Unacceptable - using unapproved abbreviations.

Findings:

Documents Reviewed:

Review of the BHB Glucometer Control log for August 2022 fourteen entries were documented on the form column titled "RN Legible Signatures", for August 1 through the 14th. All documented signatures (4) were illegible along and nine documented what appeared to be just initials.

Medical Record Forms

Patient (ID # 1)

8/3/2022 - 7a-7p - Patient Medical Assessment signed by Staff (ID #W) with first name only followed by LVN (licensed vocational nurse) no last name documented.

8/3/2022 - 7a-7p - Treatment Plan Progress Note Psychiatric signed by Staff (ID #W) with first name only followed by LVN (licensed vocational nurse) no last name documented, no date and time of entry.

8/2/2022 - Multidisciplinary Progress signed by Staff (ID #X) with no title following signature.

8/3/2022 - Multidisciplinary Progress signed by illegible signature.

8/8/2022 - Progress Note- electronically signed by on 8/06/22 by NP staff (ID #G) (Nurse Practitioner). Electronically signed by physician staff (ID #H) on 8/08/22. Physician denies he signed his electronic signature.

Patient (ID #2)

8/11/2022 - High Risk Notification Alert signed by staff (ID #K) with first name and last initial only along with title.

8/11/2022 - Level of Care Recommendation Form signed by staff (ID #K) with first name and last initial only and no title.

8/11/2022 - Psychiatric SBAR - Intake to unit Patient Report Worksheet signed by staff )ID #K) with first name and last initial only along with title.

8/11/2022 - Report of Collateral Information signed by staff (ID #K) with first name and last initial.

Patient (ID #3)

6/2022 - Report of Collateral Information signed by illegible signature documented title RN legible.

Interview and record review with Director of HIM, Medical Records, staff (ID #J) on 08/16/2022 confirmed the above signature for patient (ID #2's) medical records were not acceptable. Staff (ID #J) confirmed the signature should be legible and include the first initial, or first name along with the last name and the credentials of the persons signing the documents. Staff (ID #J) confirmed the hospital had identified some issues with signatures in medical records.

Interview on 8/16/2022 at 1550 with registered nurse, staff ID (#K) confirmed she signed the medical record documents as her first name and last name initial. Staff (ID #K) confirmed she always signs her name this way and was unaware that she needs to include her last name and her credentials with her signature.

Interview with Staff (ID #H) stated in an interview on 8/17/2022 that he was out of the country from 7/26/2022 through 8/11/2022 and never saw the patient (ID #1) or signed the progress note or authorized anyone to sign his electronic signature. Staff (ID #H) confirmed he does not know his electronic signature got on the document and you must sign electronic signature with a code.


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37322

Based on record review and interview the facility failed to ensure the progress notes were accurate.

Findings Included:

Record review of the facility policy of "Information Services" reviewed 12/14/20 stated; ensuring that uses have secure and confidential passwords is a critical element in the overall strategy of protecting UHS system data,
Record review of facility policy

Record review of the facility policy "Documentation in the Patient's Medical Record, reviewed 05/17/22 stated never leave blank areas in the medical record, if lines are inadvertently left blank a line should be immediately marked through these unused lines to indicate no entry will be made.

Patient (ID#1) was admitted to MD (ID# H) on 07/26/2022..

Record review of two consents signed by nurse (ID# AA) for treatment for the following medications which was left blank on 07/31/2022 at 2250 and 2250, 07/31/2022. The consent was signed by another physician (ID# P) whose signature was not legible dated 08/04/2022 at 1210.

Record review of the multidisplinary progess notes dated 08/03/2022 at 1400 revealed the patient was transfered to the hospital for dehydration.

Interview on 08/17/2022 at 0941 with psychiatrist MD, (ID#H) stated:
I was on vacation from 08/26/2022 to 09/11/2022.
I never talked to the patient family, my NP (ID# G) was here, you should see her notes. Dr. (ID#P) was covering for me.
He stated he was unaware that this electronic signature was being used to co-sign the NP notes.

Interview on 08/18/2022 at 1705 with the PI Coordinator (ID#B) who verified Dr. (ID#P) signature and stated his name should be on top of the medication consent, not Dr. (ID#H).

Based on observation, interviews, and review of facility documentation the facility failed to follow current professional infection control standards for healthcare facilities related to blood glucose glucometer use as set forth by the CDC (Centers for Disease Control & Prevention). This was evidenced by not following current CDC guidelines and manufactures guidelines in that single person glucometers were used for testing of multiple patients and glucometers were not properly cleaned or disinfected after use.

The facility has 10 current diabetic patients requiring multiple glucose testing daily exposing the patients to risk of infection and spread of disease which can result in actual harm to patients.

Policy Reviewed:

Review on 08/17/2022 of the facility's current Infection Control Policy and Procedures titled, "Hospital Equipment Cleaning", Date reviewed 05/17/2022, approved by Board of Governors. Purpose: To maintain a clean environment and reduce the possibility of cross-contamination between patients. Policy: 3. Equipment used routinely during the day shall be cleansed after each use per national healthcare regulatory standards. When none are specified, patient equipment will be cleaned per the manufacturer's instructions or with and EPA approved hospital germicidal wipe/disinfection. Example of these are...b. Blood Glucose machines.

Review of the Center for Disease Control web site: https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html. Infection Prevention during Blood Glucose Monitoring and Insulin Administration.

Best Practices for Assisted Blood Glucose Monitoring and Insulin Administration
The following are infection control recommendations that anyone who performs or assists with blood glucose monitoring and /or insulin administration should review to assure they are not placing themselves or persons in their care at risk.

These recommendations apply not only to licensed healthcare facilities but also to any setting where fingerstick procedures are performed and/or insulin is administered, including assisted living or residential care facilities, clinics, health fairs, shelters, detention facilities, schools, and camps. Protection from bloodborne viruses and other infections is a basic requirement and expectation anywhere healthcare is provided.

Recommended Practices for Preventing Bloodborne Pathogen Transmission during Blood Glucose Monitoring and Insulin Administration in HealthCare Settings:

Blood Glucose Meters:

Whenever possible, glucose meters should be assigned to an individual person and not shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared.

Surveyor called the phone number listed on the back of the glucose meter 1-800-803-6025 and conducted a telephone interview on 08/16/2022 with a Trividia Health service representative. The representative confirmed they sale True Metrix glucose meters to multiple suppliers including HEB and McKesson. Surveyor confirmed the meters may have the suppliers name on the meter such as HEB or McKesson True Metrix. Surveyor was given the HEB inControl True Metrix Serial #T02949526.

Service representative confirmed it was one of their members. Service representative was questioned if the meter was for a single person use or if it could be used on multi persons. Service representative stated the meter is for single person use only and is not to be shared. Representative stated the manual for use could be found on their web site Trividiahealth.com and the information for single person use only is in the manual.

Surveyor reviewed the Trividiahealth.com website and the user manual was found with the following information:

TRUE METRIX self-monitoring blood glucose system owner's booklet.
Page 1 - Introduction: True Metrix Self Monitoring Blood Glucose System is intended for quantitative measurements of glucose (sugar) in fresh capillary whole blood samples drawn from the fingertip or the forearm. The TRUE METRIX Self Monitoring Blood Glucose System is intended to be used by and single person and not to be shared.

The TRUE METRIX Self Monitoring Blood Glucose System is intended for self-testing outside the body by people with diabetes at home and to aid to monitor the effectiveness of diabetes control.

IMPORTANT INFORMATION:
The TRUE METRIX Self Monitoring Blood Glucose System is for one person use ONLY. DO NOT share your meter or lancing device with anyone, including family members, Do not use on multiple patients!!
All parts of your blood glucose monitoring system could carry blood-born pathogens after use, even after cleaning and disinfecting.

CARE, CLEANING/DISINFECTING AND TROUBLESHOOTING
Do not share your meter with anyone, including family members.

METER CARE, CLEANING AND DISINFECTING:
Cleaning removes blood and soil from the meter.
Disinfecting removes most, but not all possible infectious agents (bacteria or virus) from the meter, including blood-born pathogens. Clean and disinfect immediately after getting any blood on the meter or if meter is dirty.
Clean and disinfect meter at least once a week. Meter may be cleaned and disinfected once a week for up to 5 years.
Cleaning (step 2) must occur before disinfecting (step 3 and 4).

To Clean and Disinfect the Meter: 1. Wash hands thoroughly with soap and water. 2. To Clean: Make sure meter is off and test strip is not inserted. With ONLY Super Sani-Cloth Wipes, rub the entire outside of the meter using 3 circular wiping motions with moderate pressure on the front, back and left side, right side, top and bott of meter. Discard used wipes. 3. To Disinfect: using fresh wipes, make sure that all outside surfaces of the meter remain wet for 2 minutes. Make sure no liquids enter the Test Port or another opening in the meter. Let meter air dry thoroughly before using to test. Note: Other disinfectants have not been tested. The effect of other disinfectants used interchangeably has not been tested with the meter. Use of disinfectants other than Super Sani-Cloth Wipes may damage meter.

Findings:

Observation on 08/16/2022 at 1145 of Unit 4 medication room along with registered nurse (RN) (ID #M) the handheld glucose monitor was observed to have a red colored droplet and smear on the front surface of the glucose monitor along with a red colored smear on the back surface of the glucose monitor. Glucometer was observed to be a HEB in control True Metrix Glucose Monitor (SN # T02949526). Manufactures guidelines limit this glucometer model for single patient use only and not to be shared between patients. Unit 4 current has four diabetic patients requiring blood glucose testing.

Interview on 08/16/2022 with staff (ID #M )confirmed that Unit #4 currently has diabetic patients maybe three or four that require blood glucose finger sticks and the patients' blood is tested using this glucometer. Staff (ID #M) confirmed she had used the glucose monitor identified as a HEB in Control True Metrix Glucose Monitor, serial # T02949526 earlier to check patients' blood sugars on the unit. Staff (ID #M) confirmed, and she had wiped down and disinfected the glucometer after each use with a Sani-Cloth disinfecting wipes before returning it to the clean area.

Staff (ID #M) confirmed the meter was used on multiple patients on the unit and had disinfected the glucometer and the glucometer was ready to be used. Surveyor pointed out the reddish droplet and smear on the glucose monitor to Staff (ID #M) who verified the red droplet and smear on the glucometer.

Observation on 08/16/2022 at 1615 of Unit 8 medication room along with Chief Nursing Officer, staff (ID #D) and registered nurse, staff (ID #O) the surveyor observed 1 glucose meter located in the medication room identified as a True Metrix Pro Glucometer. Manufactures guidelines allow for shared patient use with proper cleaning and disinfection between patient use with this meter. Unit 8 currently has one diabetic requiring blood glucose testing.

Interview with staff registered nurse (ID#O) as asked how she cleans and disinfects the glucometer. Staff (ID #O) replied she cleans the glucometer with alcohol swabs between patients, and at the start and end of the day she disinfects with Super Sani-cloth.

Interview with Staff (ID #D) stated that staff know how to disinfect meters and Sani-Cloth disinfecting wipes should be used, not alcohol.

Observation on 08/16/2022 at 1630 of Unit #5 along with Staff (ID #D) and registered nurse (ID #P) revealed one glucometer identified as a HEB in Control True Metrix Glucose Monitor. Manufactures guidelines limit this glucometer model for single patient use only and not to be shared between patients. Unit #5 currently has a census of 3 diabetic patients requiring blood glucose testing.

During an interview on 08/17/2022 the surveyors shared with the facility's Chief Nursing Officer, staff (ID #D) and Chief Operations Officer, staff (ID #C) two pictures taken on 08/16/2022 during the initial tour of the facility. Pictures shared were of two HEB in Control True Metrix Glucose Monitor found on Units 4 and 5 that were identified to be single person use glucometers only and not to be shared per the manufacturer's recommendations. Additional shared pictures included three additional glucometers found in Unit 6, 7 and 8 that were identified to be McKesson

True Metrix Pro glucometer which were identified by the manufacturer's recommendation to be for militiaperson use. Staff confirmed the two glucometers in the pictures were HEB in Control True Metrix Glucose Monitor and not the McKesson True Metrix Pro glucometer.

Interview on 08/17/2022 with the Performance Improvement Director, staff (ID #B) on 08/17/2022 stated they did not have the HEB in Control True Metrix Glucose Monitor in their facility and only used the McKesson True Metrix Pro glucometer. A tour of the medication rooms for Units 4,5,6, 7 and 8 along with staff (ID #A, B, C, D and F) revealed:

Units 6,7 and 8 all had McKesson True Metrix Pro glucometer.

Unit 5 where the HEB in Control True Metrix Glucometer (single person use) was found on the initial tour was not found on the follow-up observation, a McKesson True Metrix Pro glucometer was found.

Unit 4 where the HEB in Control True Metrix Glucometer (single person use) was found on the initial tour was not found on the follow-up observation, two McKesson True Metrix Pro glucometer was found. Surveyor questioned Staff (ID #B) on where the HEB in Control True Metrix Glucometer was that was identified yesterday, he responded that these meters are the ones the staff use on the unit. Survey questioned staff (ID #B) who again confirmed these were the only two meters used to test blood glucose on the unit, and they do not have any HEB in Control True Metrix Glucometer.

Surveyor questioned what happened to the meter that was seen yesterday. The Chief Executive Officer, (staff #A) replied, "I do not like what you are was insinuating".

Surveyor turned on True Metrix Pro glucometer (SN #TPO42446) and the monitor displayed the current date and time on the meter screen, memory history was recalled, and the last blood glucose testing was documented as 07/09/22 at 1030. Staff (ID#D) confirmed this was the last date and time the glucometer had been used.

Surveyor turned on True Metrix Pro glucometer (SN #TP0648643) and the monitor displayed the current date and time on the meter screen, memory history was recalled, and the last blood glucose testing was documented as 04/20/22 at 1037. Staff (ID#D) confirmed this was the last date and time the glucometer had been used.

No additional comments were received from the staff.

Based on record review the governing failed to ensure the psychiatry evaluation was completed in a timely manner on one of one patients (ID#1).

Record review of an incomplete initial psychiatry evaluation revealed the exam was documented as complete for patient (ID#1) on 07/30/2022. Patient (ID#1) was admitted 07/26/2022 and electronically signed by the physician (ID# P) on 08/01/2022 at 0852.

No additional documentation was received.