HospitalInspections.org

Based on observation, document review and staff interviews the hospital staff failed to provide multi patient use glucometers and glucometer specific strips for measuring accurate blood glucose for patient care. Failure to provide multi patient use glucometers and glucometer specific strips with the appropriate usage of controls (solutions used to test the functionality of the meter and test strips) may result in inaccurate blood glucose readings which may lead to inappropriate patient care and harm. The hospital reported the hospital staff performed an average of 192 blood sugar checks per month starting in June 2020. The patient census was 29 on the day of entrance.

Findings include:

1. Observation on 2/9/2021 at 11:40 AM, during a tour of the hospital, revealed several different glucose monitors (a medical device used for determining the approximate concentration of glucose (the main type of sugar in the blood and is the main source of energy for the body's cells) in the blood ... A small drop of blood, obtained by pricking the skin with a lancet, is place on a disposable test strip that the meter reads and uses to calculate the blood glucose level) were available for blood sugar checks: 2 -- Harmony Blood Glucose Monitoring Systems intended for multiple patient use, 1 -- True Focus Blood Glucose Monitoring System intended for single patient use, and 3 -- True Metrix Blood Glucose Systems intended for single patient use. Upon further review the blood glucose control logs were not updated daily per policy.

2. Review of the Harmony Blood Glucose Monitoring System manufacturer's information, revealed in part, "It is intended for multiple patient use in professional healthcare settings ..."

3. Review of the True Focus Blood Glucose Monitoring System manufacturer's information, revealed in part, "Intended to be used by a single patient and should not be shared ..."

4. Review of the True Metrix Blood Glucose System manufacturer's information, revealed in part, "... is intended to be used by a single patient and should not be shared ..."

5. Review of the Eagle View Hospital Glucometer Accession log revealed the lack of monitoring the control solutions for each glucometer used.

6. During an interview on 2/9/2021 at 12:32 PM, with RN A admitting all the blood glucose monitors in use were used for multiple patient blood glucose checks. RN A revealed the blood glucose control logs are to be completed by the night shift staff.

7. During an interview on 2/9/2021 at 12:55 PM, with the Interim Director of Nursing (DON) verified there should be a completed log for each blood glucose monitoring system. The Interim DON acknowledged a completed log for the blood glucose monitoring systems were not available to review.

4. The surveyor reviewed the above findings with the CEO, the Interim DON, and the DON. The hospital provided no additional information prior to the end of the survey.