HospitalInspections.org

Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure Emergency Department (ED) staff followed the manufacturer's instructions for the TRUE METRIX self monitoring blood glucose system glucometer (device used to check a patient's blood sugar level), when the ED staff utilized the device, intended for use on a single patient, for multiple patients. Failure to follow the manufacturer's instructions for single patient use only, may result in the inability to adequately disinfect the glucometer after each use, and exposed patients subsequently tested with the glucometer, to blood-borne pathogens that may result in a serious or life threatening infection. The CAH administrative staff identified 95 patients had been tested with the ED TRUE METRIX glucometer since put into use in August 2022 -March 2023.


Findings include:

1. Observation on 3/27/23 at approximately 1:30 PM revealed a TRUE METRIX glucometer in the ED Medication Room.

2. Review of "TRUE METRIX Owner's Booklet" copyright 2021, located near the TRUE METRIX glucometer revealed in part, "...IMPORTANT INFORMATION:...The TRUE METRIX Self Monitoring Blood Glucose System is for one person use ONLY. DO NOT share your meter...with anyone, including family members. Do not use on multiple patients!! ALL parts of your blood glucose monitoring system could carry blood-borne pathogens after cleaning and disinfecting."

3. During an interview on 3/27/23, at the time of the observation, the ED Nurse Manager verified the TRUE METRIX glucometer was the glucometer used on all patients in the ED that required their blood glucose checked. The ED Nurse Manager verbalized surprise and reported they were not aware the TRUE METRIX glucometer was intended for single patient use only.

4. During an interview on 3/28/23 at 3:30 PM, the CNO acknowledged the ED staff had utilized a glucometer intended on use for a single patient, on multiple patients since August 2022.

Based on review of policies and procedures, document review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure policies and procedures implemented were enforced. Surgical services policies must be in accordance with acceptable standards of medical practice and surgical patient care. The CAH Administrative Staff identified a total of 1357 procedures performed during fiscal year July 1, 2021-June 30, 2022.

1. The CAH Administrative staff failed to ensure a qualified practitioner reassess a patient and update the patient's history and physical (H&P) prior to a surgical procedure.

2. The CAH Administrative staff failure to ensure if an H&P was conducted no more than 30 days and no less than the day before the surgery the H&P should be updated by a qualified practitioner prior to surgical services for a CAH patient.

Findings include:

1. Review of the CAH's Rules and Regulations policy reveals in part, "...The surgeon must sign the H&P and assume full responsibility for the H&P. An interval admission note that includes all additions to the history and any subsequent changes in the physical findings must be recorded by the surgeon with 24 hours of surgery..."

2. Review of the CAH's medical records revealed 5 of 5 charts that did not have an updated History and Physical (H&P) present prior to Patient #1, Patient #2, Patient #3, Patient #4, and Patient #5's procedures.

3. During chart review:

a. Patient#1 revealed there was not an updated H&P completed by Physician A.

b. Patient #2 revealed there was not an updated H&P completed by Physician B and the Anesthesia Consent did not contain a date and time by the patient or the Certified Registered Nurse Anesthetist (CRNA) E.

c. Patient #3 revealed there was not an updated H&P completed by Physician C.

d. Patient #4 revealed there was not an updated H&P completed by Physician D.

e. Patient #5 revealed there was not an updated H&P the Anesthesia Consent did not contain a date and time by the patient or the Certified Registered Nurse Anesthetist (CRNA) E.

4. During interview on 03/29/2023 at approximately 11:10 AM with the Director of Surgery and the Chief Nursing Officer verified there was no update to the H&P that was performed by a qualified provider found in the medical record. The Director or Surgery further acknowledged it is not the practice of the hospital to update the H&P as per the CAH's Rules and Regulations.