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Tag No.: C1016
Based on observation and staff interview, the CAH failed to ensure vials of outdated medication were not available for patient use in 1 of 3 outpatient practices observed (Orthopedic Services).
Findings include:
Observation on 9/22/2021 at 9:25 a.m. Orthopedic Services' cast room revealed 9 - 1 mL single dose vials of Depo-Medrol (lot numbers DN2937 and DC6263) medication expired August 2021 stored and available for use in the storage cabinet.
Interview on 9/22/2021 at 9:25 a.m. with Staff C (Medical Assistant) confirmed the above finding.
Tag No.: C1206
1. Based on observation, interview and policy review, it was determined that the facility failed to prevent the potential for cross contamination of infectious diseases during blood glucose monitoring on 2 of 4 units observed.
Observation on 9/21/21 at approximately 10:00 a.m. of the glucometer on Intensive Care Unit (ICU) revealed a red dried substance on the back of the glucometer.
Interview on 9/21/21 at approximately 10:00 a.m. with Staff A (CNO) and Staff B (Registered Nurse) revealed that the glucometer was ready for use. Staff B confirmed that there was a red dried substance adhered on the back of the glucometer and it was blood.
Observation on 9/21/21 at approximately 10:15 a.m. of the glucometer on obstetrics revealed a red dried substance on the back of the glucometer.
Interview on 9/21/21 at approximately 10:15 a.m. with Staff A revealed that the glucometer was ready for use. Staff A confirmed that there was a red dried substance adhered on the back of the glucometer.
Review of the facility's policy and procedure entitled "Blood Glucose monitoring, Point of Care Nova BioMedical StatStrip ... ", revealed the following instructions on page 6, 10. "All glucometers will be thoroughly wiped and allowed to air dry after each use and between every patient."
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2. Based on observations and interview, the CAH failed to follow manufacturer's instructions for the thermometer used when screening visitors for COVID-19 upon entrance to the CAH.
Findings include:
Observation on 9/21/21 at 8:55 a.m. revealed Staff E (Screener) took temperatures of 5 of 5 visitors observed by measuring the skin temperature on the inside of their wrists. The first visitors temperature was recorded as 92.6 degrees Fahrenheit.
Review 9/21/21 of the Manufacturer's Instructions (MI), not dated, of the thermometer used on 9/20/21 to measure the temperature of visitors revealed the intended use of the thermometer was "non-contact to measurement forehead temperature at home or hospital..." The MI explain how to take forehead temperatures. The MI do not have an intended use or directions for taking temperature on the inside of the wrist.
Review of facility policy titled "Covid-19 Screening Plan", not dated, revealed that "4. Screeners will take individuals' temperatures using an infrared thermometer according to the manufacturer's instructions for use. If the temperature is consistently <95.0 degrees Fahrenheit the screener will change the battery or move to an alternative device".
Interview on 9/21/21 with Staff D (Director of Quality) confirmed the intended use of the above thermometer was forehead temperature measurement.
3. Based on observation and interview, the CAH failed to follow the MI for sanitizing kitchen items in the kitchen's three part sink.
Findings include:
Review on 9/23/21 of the MI for the quaternary solution used in the kitchen's three part sink revealed that items should be immersed for at least 60 seconds in the quaternary solution then drained and air dried.
Observation on 9/23/21 at approximately 12:30 p.m. in the kitchen revealed that Staff H (Kitchen Staff) dipped a metal square bowl in quaternary solution for approximately 5 seconds and set it aside to air dry.
Interview on 9/23/21 at approximately 12:30 p.m with Staff H revealed the above practice is how they normally sanitize items.
Interview on 9/23/21 at approximately 12:30 p.m. with Staff I (Kitchen Staff) revealed that they dip items in the quaternary solution for approximately 15 seconds when they sanitize items.
Interview with Staff G (Director of Food Services ) confirmed that items should be immersed for at least 60 seconds in the quaternary solution in order to sanitize.