HospitalInspections.org

Based on facility document review, facility policy review, observation, and interview, the facility failed to have an effective infection control program in place and ensure all staff followed infection prevention techniques which led to the hospital's failure to prevent the potential spread of bloodborne pathogens (micro-organisms that are present in human blood that can cause disease in humans) between patients.

The findings included:

1. The facility failed to ensure measures to prevent the potential spread of infection were followed when 1 of 1 (Rehabilitation Nursing Tech (RNT #1) staff members observed performing blood glucose assessments failed to clean the glucometer between patients.

Refer to A749.

Based on review of "Tennessee Code Annotated 63-7-103," facility document review, medical record review, observation, and interview, the facility failed to ensure 5 of 5 patients (Patients #4, #5, #6, #7, and #8) who received bedside blood glucose assessments received those assessments by qualified licensed personnel.

The findings included:

1. Review of "Tennessee Code Annotated Title 63-7-103" revealed, "..."Practice of professional nursing" means the performance for compensation of any act requiring substantial specialized judgment and skill based on knowledge of the natural, behavioral and nursing sciences and the humanities as the basis for application of the nursing process in wellness and illness care. (2) "Professional nursing" includes: (A) Responsible supervision of a patient requiring skill and observation of symptoms and reactions and accurate recording of the facts...(E) Application of such nursing procedures as involve understanding of cause and effect..."

2. Review of the facility's document titled, "Job Description/Job Competency Evaluation...Registered Nurse" revealed, "The Registered Nurse [RN] is responsible for: Providing direct patient care to inpatients...supervising care, treatment and services of patient care provided by LPNs [Licensed Practical Nurses], RNTs [Rehabilitation Nursing Technicians], CNAs [Certified Nursing Assistants], and other staff on assigned unit and shift...Assessing and reassessing of patients...Position Requirements...License or Certification: Current RN licensure appropriate to state regulations...CPR certification..."

3. Review of the facility's document titled, "Job Description/Job Competency Evaluation...Rehab Nursing Tech" revealed, "The Rehabilitation Nurse Technician is responsible for: Providing direct patient care activities appropriate to training and competency...Assisting RN/LPN in completing tasks that support patient care activities...Completes patient care activities as assigned...Position Requirements and Essential Job Functions: License or Certification: CPR [Cardio-pulmonary Resuscitation] Education, Training and Years of Experience: One year experience in inpatient general hospital setting preferred..."

4. Review of RNT #1's personnel record revealed she was an unlicensed professional who was CPR certified.

5. Medical record review for Patient #4 revealed an admission date of 7/25/2020 with diagnoses that included Embolic Stroke with Right Hemiparesis, Severe Aphasia, Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, and Hypertension.

Review of a physician's order dated 7/22/2020 revealed, "Glucose...Routine, Nurse collect..."

Observations in Patient #4's room on 7/22/2020 at 10:53 AM, revealed RNT #1, an unlicensed professional, performed the blood glucose assessment on the patient.

6. Medical record review for Patient #5 revealed an admission date of 7/15/2020 with diagnoses that included Metabolic Encephalopathy secondary to Brain Injury, Chronic Kidney Disease, Diabetes Type 2, and Hypertension.

Observations in Patient #5's room on 7/22/2020 at 10:56 AM, revealed RNT #1, an unlicensed professional, performed the blood glucose assessment on the patient.

The facility was unable to provide this surveyor with a physician's order for the blood glucose assessment observed.

7. Medical record review for Patient #6 revealed an admission date of 7/15/2020 with diagnoses that included Critical Illness Myopathy, Diabetes, Hypertension, Atrial Fibrillation, and Urinary Incontinence.

Review of a physician's order dated 7/22/2020 revealed, "Glucose...Routine, Nurse collect..."

Observations in the therapy gym on 7/22/2020 at 11:02 AM, revealed RNT #1, an unlicensed professional, completed the blood glucose assessment on the patient.

8. Medical record review for Patient #7 revealed an admission date of 7/14/2020 with diagnoses that included Metabolic Encephalopathy, Hypertension, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Chronic Kidney Disease.

Review of a physician's order dated 7/22/2020 revealed, "Glucose...Routine, Nurse collect..."

Observations in the therapy gym on 7/22/2020 at 11:06 AM, revealed RNT #1, an unlicensed professional, completed the blood glucose assessment on the patient.

9. Medical record review for Patient #8 revealed an admission date of 7/16/2020 with diagnoses that included End Stage Renal Disease requiring Hemodialysis, Diabetes, Hypertension, Chronic Obstructive Pulmonary Disease, and Anemia.

Review of a physician's order dated 7/22/2020 revealed, "Glucose...Routine, Nurse collect..."

Observations in the therapy gym on 7/22/2020 at 11:12 AM, revealed RNT #1, an unlicensed professional, completed the blood glucose assessment on the patient.

10. During an interview on 7/21/2020 at 1:55 PM, RNT #2 was asked what her job duties were and the RNT stated, "Give baths, make sure they (patients) stay clean...do accu checks [blood glucose assessments]..."

During an interview on 7/21/2020 at 3:50 PM, Nurse #1 was asked who usually performed the blood glucose assessments and the nurse stated, "The techs [RNTs]..."

During an interview on 7/22/2020 at 11:50 AM, the Human Resources Director verified the facility did not require RNTs to be licensed or certified in anything other than CPR.

Based on facility document review and interview, the facility failed to have a full-time employee in place who served as the director of the food and dietetic services from 5/19/2020 through 7/21/2020, and the failed to ensure dietary staff members recorded food temperatures from 4/29/2020 through 7/20/2020.

The findings included:

1. During an interview on 7/21/2020 at 11:35 AM, the Chief Executive Officer (CEO) informed this surveyor the facility had been without a Dietary Manager or Interim Dietary Manager since late May of 2020.

2. During an interview on 7/21/2020 at 3:25 PM, the Registered Dietician (RD) was asked if she was providing supervision and over site of the kitchen staff since the facility had no Dietary Manager and the RD stated, "I haven't been appointed, but if they have any questions about the temperatures or menus or anything, I fill in there."
The RD was asked if she went in the kitchen to observe dietary staff preparing the food and performing temperature checks. The RD verified she did not actively go into the kitchen unless staff members had questions.

3. During an interview on 7/22/2020 at 11:35 AM, the Human Resources Director stated the Dietary Manager position had been vacant since 5/19/2020.

4. The facility was unable to provide documentation that the food temperatures were obtained from 4/29/2020 through 7/20/2020.

During an interview on 7/21/2020 at 3:35 PM, Dietary Cook #1 verified there was no documentation of the food temperature checks.

Based on facility document review, facility policy review, observation, and interview, the facility failed to ensure measures to prevent the potential spread of infection were followed when 1 of 1 (Rehabilitation Nursing Tech (RNT #1)) staff members observed performing blood glucose assessments who failed to clean the glucometer (a device to test the level of blood glucose in patients) between patients for 5 of 5 (Patients #4, #5, #6, #7 and #8) patients observed being tested for blood glucose levels by the RNT.

The findings included:

1. Review of the facility document titled, "Accu-Check Inform II In-Service Plan for Blood Glucose Testing" revealed, "...Perform any cleaning and disinfecting required by hospital policy after each patient test...Cleaning and Disinfecting the ACCU-CHECK Inform II system...Frequency of Cleaning and Disinfecting: At minimum, ACCU-CHECK Inform II meters are cleaned and disinfected following each patient use..."

2. Review of the facility policy titled, "Disinfection and Sterilization" revealed, "...Purpose To provide supplies and equipment that are adequately cleaned, disinfected or sterilized...All shared equipment that touches patients must be disinfected between patient contacts...External surfaces of common patient equipment will be cleaned with a facility approved EPA [Environmental Protection Agency] approved disinfectant and in accordance with manufacturer's instructions. The patient caregiver has ultimate responsibility for ensuring that only clean and disinfected equipment is used to care for patients..."

3. Medical record review for Patient #4 revealed an admission date of 7/25/2020 with diagnoses that included Embolic Stroke with Right Hemiparesis, Severe Aphasia, Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, and Hypertension.

Medical record review for Patient #5 revealed an admission date of 7/15/2020 with diagnoses that included Metabolic Encephalopathy secondary to Brain Injury, Chronic Kidney Disease, Diabetes Type 2, and Hypertension.

Medical record review for Patient #6 revealed an admission date of 7/15/2020 with diagnoses that included Critical Illness Myopathy, Diabetes, Hypertension, Atrial Fibrillation, and Urinary Incontinence.

Medical record review for Patient #7 revealed an admission date of 7/14/2020 with diagnoses that included Metabolic Encephalopathy, Hypertension, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Chronic Kidney Disease.

Medical record review for Patient #8 revealed an admission date of 7/16/2020 with diagnoses that included Subdural Hematoma, End Stage Renal Disease requiring Hemodialysis, Diabetes, Hypertension, Chronic Obstructive Pulmonary Disease, and Anemia.

4. Observations on 7/22/2020 beginning at 10:50 AM revealed RNT #1 obtained a glucometer from the nurse and placed it in her caddy.

The RNT walked into Patient #4's room, performed hand hygiene, donned gloves, laid the glucometer on Patient
#4's bed with the patient and assessed the patient's blood glucose level by using a sample of the patient's blood.
After performing the assessment on Patient #4, the RNT removed her gloves, performed hand hygiene, and left the patient's room. There was no observations the RNT disinfected the glucometer after using it on Patient #4.

RNT #1 walked across the hallway and entered Patient #5's room, performed hand hygiene, donned gloves, and assessed the patient's blood glucose level using a sample of the patient's blood. There was no observations the RNT disinfected the glucometer after using it on Patient #5.

RNT #1 then walked into the therapy gym, placed the glucometer onto the table beside Patient #6, performed hand hygiene, donned gloves, and assessed the patient's blood glucose level by using a sample of the patient's blood. After using the glucometer, the RNT removed her gloves and performed hand hygiene. There was no observation the RNT disinfected the glucometer after using it on Patient #6.

RNT #1 walked across the gym and placed the glucometer on a stool beside Patient #7. The RNT performed hand hygiene, donned gloves, and assessed the patient's blood glucose level using a sample of Patient #7's blood. After using the glucometer, the RNT then removed her gloves and performed hand hygiene. There was no observations the RNT disinfected the glucometer after using it on Patient #7.

RNT #1 then walked across the gym and placed the unclean glucometer on a rolling table beside Patient #8. RNT #1 performed hand hygiene, donned gloves, and assessed the patient's blood glucose level using a sample of the patient's blood. There was no observations the RNT disinfected the glucometer after using it on Patient #8.

After using the glucometer on Patient #8 the RNT placed the used, dirty glucometer back into the carrying caddy without disinfecting the glucometer.

RNT #1 failed to clean the glucometer between patient use repeatedly potentially exposing each patient to infectious agents.

9. During an interview on 7/22/2020 at 11:13 AM, the Chief Nursing Officer was asked how often the glucometers should be cleaned. She stated, "Between patients you're supposed to wipe them down."