HospitalInspections.org

Based on hospital policy review, medical record review, pharmacy training material, observation and staff interviews, the hospital failed to ensure hand hygiene was performed per hospital policy for 3 of 7 observations of patient care (Pt. #7, 15, 16); failed to ensure point of care blood glucose monitors were cleaned between patient use for 1 of 1 observed blood glucose tests (Pt. # 19); failed to ensure point of care blood glucose monitor Hi Lo controls were not used beyond expiration date for 8 of 11 point of care blood glucose monitors; and failed to replace 1 of 3 Black Bins containing sharps when the fill line was reached.

Findings include:

Policy review on 04/14/2016 revealed "Hand Hygiene and Hand Care" review/revised 11/15/2013. Policy review revealed "...PURPOSE: To remove microbial contamination of the hands acquired by contact with infected or colonized person, body fluids or environmental sources. Hand hygiene is the single most important strategy to reduce the risk of transmitting organisms from one person to another or from one site to another on the same patient...F. Gloves and Hand Hygiene 1. Gloves do not eliminate the need for hand hygiene. . .2. Hand hygiene shall be performed after removing gloves. 3. Change gloves and perform hand hygiene during patient care when moving from a contaminated site to a clean site... "

Policy review on 04/14/2016 revealed "Glucose Testing on Whole Blood" review/revised 08/25/2015. Policy review revealed "...PURPOSE: To ensure the proper performance of glucose (sugar) monitoring, and to verify that the glucose meter and test strips are functioning properly...C. Quality Control Testing...4. Reagents (Hi Lo solutions) should not be used past their expiration date...ACCU-CHECK Inform II Control...solutions expire on the dated printed on the vial label, or 3 months from opening, whichever comes first. Whenever an operator opens a vial of controls...solutions, he/she will handwrite the expiration date and his/her initial on the vial. The expiration date will be either 3 months from opening or the date printed on the vial label, whichever comes first...L. Cleaning and Disinfecting the ACCU-CHECK Inform II System Components 1...Meters approved for use with multiple patients will be disinfected after each patient use..."

Policy review on 04/14/2016 revealed "Guidelines for Isolation Precautions" review/revised 07/01/2014. Policy review revealed "...PURPOSE: To prevent the spread of communicable disease within the hospital. To prevent cross infection between patients and hospital personnel. To prevent uninfected persons from contact with potentially pathogenic microorganisms...C. CONTACT PRECAUTIONS...use Contact Precautions...for specified patients known or suspected to be infected...with...important microorganisms that can be transmitted by direct contact with the patient (hand or skin-to-skin contact that occurs when performing patient-care activities that require touching the patient's dry skin) or indirect contact (touching) with environmental surfaces or patient-care items...2. Gloves and Hand washing a...During the course of providing patient care...change gloves after having contact with infective material...Remove gloves before leaving the patient's room and perform hand hygiene immediately...After glove removal and hand hygiene, ensure that hands do not touch potentially contaminated environmental surfaces..."

Policy review on 04/14/2016 revealed "Pharmaceutical Waste Management" review/revised 01/01/2013. Policy review revealed "...PURPOSE: To ensure safety in the handling and appropriate disposal of pharmaceutical wastes. DEFINITIONS: Pharmaceutical Waste...is defined as any partially used medications, vials or containers that held "P-Listed" drugs to include partial vials, bottles, I.V. bag tubing...2. Disposal...This hazardous material must be segregated from the sharps and contaminate material disposed of in red, plastic, sharps containers...Examples of waste product: used needles and syringes, empty drug vials and ampoules...When the container is filled, it is transported to the hazardous disposal storage area for pick up..."

1. Open medical record review on 04/12/2016 for Patient #7 revealed a hospital admission on 04/01/2016 with diagnoses including pneumonia. Further review revealed a central line triple lumen intravenous (IV) catheter was inserted on 04/04/2016 into the patient's right neck for fluids and medications.

Observation on 04/12/2016 at 1330 during a sterile dressing change of the central line IV catheter revealed Registered Nurse (RN) #1 donned gloves and removed the old dressing. RN #1 removed the dirty gloves and donned sterile gloves. The observation revealed RN#1 did not perform hand hygiene after removing the dirty gloves and prior to donning sterile gloves.

Interview on 04/12/2016 at 1400 with the Assistant Chief Nursing Officer regarding the observation with Patient #7, revealed hand hygiene should have been performed after dirty gloves were removed and prior to donning sterile gloves.







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2. Open medical record review on 04/13/2016 for Patient #15 revealed a hospital admission on 04/09/2016 with a diagnosis including Pneumonia. Further review revealed the patient was also Immunosuppressed (low immune system) secondary to chemotherapy treatment.

Observation on 04/13/2016 at 1340 during the unit tour revealed RN #2 (registered nurse) exited Patient #7's room without performing hand hygiene after removing dirty gloves. Observation revealed RN #2 obtained supplies and returned to the patient room without performing hand hygiene prior to donning clean gloves.

Interview on 04/13/2016 at 1345 with the nurse manager, regarding observation with Patient #15, revealed hand hygiene should have been performed after dirty gloves were removed and prior to donning clean gloves. Interview further revealed, "We do well foaming out but not so well with foaming in and prior to putting on clean gloves but we are working on that and our numbers are improving. It's an ongoing improvement initiative we take very seriously."

3. Open medical record review on 04/12/2016 for Patient #16 revealed a hospital admission on 04/05/2016 with a diagnosis including Diabetic foot ulcers (open sore) and Uncontrolled Diabetes. Further review revealed a positive Methicillin Resistant Staphylococcus Aureus (MRSA: antibiotic resistant bacteria) nasal swab on admission with Contact Precautions initiated at that time.

Observation on 0412/2016 at 1030 during the unit tour revealed RN #4 entering data in the Workstation on Wheels (WOW) with gloved hands. Observation revealed RN #4 provided patient care and returned to the workstation without removing gloves and performing hand hygiene prior to continued data entry.

Interview on 04/12/2016 at 1035 with the Nurse Manager and Assistant Chief Nursing Officer, regarding observation with Patient #16, revealed it is acceptable practice to have used gloved hands when accessing the keyboard of the WOW. Interview revealed gloves can be used when entering data via the WOW, "if the keyboard is wiped down."

Interview on 04/13/2016 at 0900 with the Infection Control Preventionist, regarding observation with Patient #16, revealed "Best practice would be to remove gloves, perform hand hygiene, enter data, and then redonn (put on) clean gloves. They (nursing staff) should also clean the keyboard between patients. Interview revealed the contaminated gloves should have been removed, with hand hygiene performed following, and then data entry via the keyboard.

4. Open medical review on 04/13/2016 for Patient #19 revealed a hospital admission on 04/10/2016 with a diagnosis including Diabetes. Further review revealed orders on 04/10/2016 at 1442 for finger sticks before meals and at bedtime.

Observation on 04/13/2016 at 1640 revealed CNA (certified nursing assistant) #1 performing an Accu check (fingerstick) to determine the patient's (#19) blood sugar. Observation revealed that following the Accu check, the monitor was placed back into the docking station without being cleaned.

Interview on 04/13/2016 at 1645 with CNA #1 revealed the Accu check monitors are cleaned weekly and "Only wiped down between patients if they are on some type of precautions." Interview at 1650 with CNA #2 revealed "I usually wipe it down after each patient but it's just something I do extra. They (Accu check monitors) don't have to be wiped down between patients unless they are on precautions." Interview at 1655 with the nurse manager revealed "That is not how it should be done. Monitors have to be wiped down after each patient regardless of precaution status."

5. Observations during unit tour on 04/12/2016 at 1140 revealed three (3) Hi Lo solutions labeled with an expiration date of 04/07/2016. Observations revealed three (3) additional Hi Lo solutions with no label. Observation of Patient #19's Accu check on 04/13/2016 at 1640 revealed both Hi Lo solutions were labeled with an expiration date of 04/12/2016.

Interview on 04/12 2016 at 1140 with the nurse manager revealed nursing staff are expected to label HiLo solutions with the expiration date when opened. Interview revealed HiLo solutions were out of date and should not be available for use. Interview revealed use of expired HiLo solutions is not acceptable practice.

6. "RCRA (Resource Conservation and Recovery Act) Pharmacy Training" review on 04/14/2016 revealed "...The guidelines that should be followed when disposing hazardous meds (medications) into the Black Bins are as follows:...4. Do NOT place needles into Black Bins or other Hazardous Waste receptacles. Place needles in sharps containers..5. Black Bins...must be kept closed and secure when not in use. 6. When Black Bin is approximately three-fourths (3/4) full, complete the Chemical/Haz Waste Pickup form..."

Observation during tour of the medication room on 04/12/2016 at 1100 revealed an opened Black Bin containing sharps (needles, glass vials, glass ampoules) above the fill line (more than 3/4 full). Observation revealed the Black Bin's top access slide was propped open.

Interview on 04/12/2016 at 1100 with the nurse manager revealed the Black Bin lid was not designed to prop open and that it should remain closed when not in use to prevent needle sticks. Interview revealed "We remind nursing staff during our meetings but it still happens on occasion." Interview on 04/13/2016 at 1540 with the ICP (Infection Control Preventionist) revealed "glass vials and ampoules" are considered "sharps" and present a risk of injury. Interview revealed all sharps, including needles, should be disposed of in the designated sharps box, not the Black Bin, and that the Bin should be replaced when it reaches the fill line.

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