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Based on interview and record review the facility's governing body failed to ensure oversight of their Contracted services when the Contracted Laboratory put single use glucometers (used to measure blood glucose levels) into use on patients without providing a policy and procedure and providing staff training resulting in 211 patients, requiring blood glucose monitoring, at risk of being exposed to blood borne pathogens.

Refer to Contract Services A083

Based on interview and record review the facility's governing body failed to ensure oversight of the Contracted services when the Contracted Laboratory put single use glucometers (used to measure blood glucose levels) into use on patients without providing a policy and procedure and providing staff training resulting in 211 patients, requiring blood glucose monitoring, at risk of being exposed to blood borne pathogens.

Findings Include:

Observation on the morning of 6/5/18, on the inpatient unit revealed Staff, #8, tech using the Quintet Glucose Monitor. When asked if the glucometer is used on multiple patients Staff #8 stated "Yes." When asked how the monitor is cleaned, Staff #8 stated, "I use the wipes between patients."

On the morning of 6/5/18, during an interview on the inpatient nursing unit, when Staff #6, RN was asked if she uses the glucometer stated the glucometers were used between patients.

On the morning of 6/5/18, during an interview on the inpatient nursing unit Staff #7, RN when asked how they were trained in the use of the new glucometers RN stated, "There was a sign-in sheet, it isn't there anymore.... We use the purple wipe to clean the meters between patients."

During an interview on the morning of 6/6/18, in the administrator's office, Staff #1, Chief Nursing Officer stated, "On 5/1/18 we switched the management of the lab, the previous company took all their equipment...Qmed was contracted to run the lab... the consultant of the lab said we could use this (glucometer) for now.... We've ordered the hospital grade glucometers, but we are using these until we can get the hospital glucometers." When asked how the facility choose the current glucometer Staff #1 stated, "We looked at the ones the staff would want to use..." When asked how the staff were trained on the use of the new glucometers, Staff #1 stated, "Staff #4 (Supervisor of the lab) would have done the training. "When asked if the facility had a policy and procedure for the use of the temporary glucometers Staff #1 stated, "Not that I'm aware of."

The surveyor asked on multiple occasions for the manufacturer's instruction manual for the Quintet blood glucose monitor the facility was currently using. Staff #10, Laboratory supervisor stated, "We threw the boxes out because they took up too much space." Staff #10 could not provide any information on the use and cleaning of the monitors.

During a telephone interview on the morning of 6/6/18, in the conference room, Staff #3, Laboratory Technical Consultant when asked about the Quintet blood glucose monitors stated, "... The glucometer is one per patient, it is a single use glucometer.... we give them to the patient when they leave... I wasn't involved in the training."

During an interview on the morning of 6/6/18, in the conference room Staff #2, Laboratory Manager stated, "We had to find something to use while we wait for the hospital grade glucometers to come in...."

During an interview on the morning of 6/6/18, in the conference room, Staff #10, Lab Supervisor confirmed he trained some nurses but did not ensure all the staff likely to conduct blood glucose monitoring had been trained and did not provide written material to the staff.

Review of the facility provided list reflect 211 patients had received blood glucose checks with shared single use glucometers.

Based on interview and record review the facility failed to provide care in a safe setting when single use glucometers were used on 211 patients requiring blood glucose monitoring, placing them at risk for cross contamination from blood borne pathogens.

refer to A144

Based on interview and record review the facility's Infection Control Program failed to intervene and prevent the use of single use blood glucometers on 211 patients requiring blood glucose monitoring, placing them at risk for cross contamination from blood borne pathogens.

Findings include:

During an interview on the morning of 6/6/18, in the administrator's office, Staff #1, Chief Nursing Officer stated, "On 5/1/18 we switched the management of the lab, the previous company took all their equipment ...Qmed was contracted to run the lab ...the consultant of the lab said we could use this for now .... We've ordered the hospital grade glucometers, but we are using these until we can get the hospital glucometers." When asked how the facility choose the current glucometer Staff #1 stated, "We looked at the ones the staff would want to use ..." When asked how the staff were trained on the use of the new glucometers, Staff #1 stated, "Staff#4 (Supervisor of the lab) would have done the training." When asked if the facility had a policy and procedure for the glucometers Staff #1 stated, "Not that I'm aware of."

During a telephone interview on the morning of 6/6/18, in the conference room, Staff #3, Laboratory Technical Consultant stated, "...The glucometer is one per patient, it is a single use glucometer.... we give them to the patient when they leave... I wasn't involved in the training."

During an interview on the morning of 6/6/18, in the conference room Staff #2, Laboratory Manager stated, "We had to find something to use while we wait for the hospital grade glucometer...."

During an interview on the morning of 6/6/18, in the conference room, Staff #10, Lab Supervisor confirmed he trained some nurses, but did not ensure all the staff likely to conduct blood glucose monitoring had been trained and did not provide written material to the staff.

On 6/6/18 at 2:24 p.m. the facility's contracted Laboratory provided a new procedure for the temporary use of the Quintet glucose monitoring system while the facility receives the hospital grade glucometer. The procedure reflected, "... It's for single patient use only."

Review of the facility provided list reflected 211 patients had received blood glucose monitoring using the shared glucometers.

Review of the facility provide Patient's Right (undated) reflected, "...The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned...."

Based on interview and record review the facility' Infection Control Program failed to prevent the use of single use glucometers from being shared, resulting in 211 patients being exposed to blood borne pathogens.

Findings include:

During an interview on the morning of 6/6/18, in the administrator's office, Staff #1, Chief Nursing Officer stated, "On 5/1/18 we switched the management of the lab, the previous company took all their equipment ...Qmed was contracted to run the lab ...the consultant of the lab said we could use this for now .... We've ordered the hospital grade glucometers, but we are using these until we can get the hospital glucometers." When asked how the facility choose the current glucometer Staff #1 stated, "We looked at the ones the staff would want to use ..." When asked how the staff were trained on the use of the new glucometers, Staff #1 stated, "Staff#4 (Supervisor of the lab) would have done the training." When asked if the facility had a policy and procedure for the glucometers Staff #1 stated, "Not that I'm aware of."

During a telephone interview on the morning of 6/6/18, in the conference room, Staff #3, Laboratory Technical Consultant stated, "...The glucometer is one per patient, it is a single use glucometer.... we give them to the patient when they leave... I wasn't involved in the training."

During an interview on the morning of 6/6/18, in the conference room Staff #2, Laboratory Manager stated, "We had to find something to use while we wait for the hospital grade glucometer...."

During an interview on the morning of 6/6/18, in the conference room, Staff #10, Lab Supervisor confirmed he trained some nurses but did not ensure all the staff likely to conduct blood glucose monitoring had been trained and did not provide written material to the staff.

On 6/6/18 at 2:24 p.m. the facility's contracted Laboratory provided a new procedure for the temporary use of the Quintet glucose monitoring system while the facility receives the hospital grade glucometer. The procedure reflected, "... It's for single patient use only."

Review of the facility provided list reflected 211 patients had received blood glucose monitoring using the shared glucometers.

Review of the facility provide policy 2017 Infection Prevention and Control Plan (reviewed 9/17) reflected, "...Purpose. Establish policies, procedure, responsibilities, and accountability for the Infection Prevention and Control Program...(6) Make recommendations for the selection, use, handling, storage and disposition of medical products or equipment which may influence infection risk when used on the patient..."