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Based on record review, observations, and staff interview, the infection control officers failed to develop a system for injection practices, personal protective equipment utilization, and point of care glucose device disinfection in a manner to maximize the prevention of infection and communicable diseases.

Findings include:
Observation on 7/28/15 of the medication room on the Madison Unit revealed an open multi-dose vial of Lantus that had not been dated by the hospital with either the date opened or discard date.

Interview with Staff A (Registered Nurse) on 7/28/15 at 9:00 a.m. revealed that it is the hospital's procedure to date all multi-dose vials when opened with a 28 day discard date.

Review of Manufacturer's instructions on 7/28/15 for the Assure Platinum Glucose Meter revealed the meter should be cleaned and disinfected by "...using a commercially available EPA-registered disinfectant detergent or germicide wipe."

Review of the hospital's procedure titled "Cleaning of Patient Care Equipment" on 7/28/15, revealed that "Glucometers, blood pressure cuffs, stethoscopes, etc. must be cleaned with a disinfectant cloth, such as Sani-Wipes between each patient or before going into storage".

Interview with Staff A on 7/28/15 at 9:00 a.m. revealed that Staff A would use an alcohol swab to disinfect the glucose meter between patients.

Observation on 7/28/15 of the soiled utility room revealed a hopper sink used by staff for pre-cleaning laundry. There was no personal protective equipment located in the soiled utility room.

Interview with Staff B (Director of Support Services) on 7/28/15 at 11:00 a.m. confirmed the above finding and revealed there was personal protective equipment available on the unit.

Based on review of procedures and interview, the facility failed to ensure that re-admissions to the hospital were part of a systemic process for discharge planning reassessment activities.

During policy and procedure review on 7/28/15, it was identified that there was no process in place to collect and analyze the data from all hospital readmissions and to use this information when developing the discharge planning activities for hospital patients.

During interview with members of Hampstead Hospital Staff on 7/28/15, it was confirmed that while the hospital does look at some re-admissions on a case to case basis, there is no formal process for collecting and analyzing this information to be used in the ongoing discharge planning process.