Every finding on record at Lee Memorial Hospital Skilled Nursing Unit

Based on observation, staff interview, and record review, the facility failed to follow the facility's policy and the manufacturer's recommendations for cleaning and disinfecting a glucometer for 1 resident (Resident #999) of 3 residents reviewed who had physicians' orders for blood sugar testing. Blood glucose meters can transmit blood-borne pathogens if these devices are contaminated with blood and are shared between users without effective cleaning, disinfecting, and appropriate infection control measures. The facility used an unapproved procedure and product to disinfect the glucometer. This has the potential to spread blood-borne pathogens among residents who require blood sugar testing. The findings included: 1. Observation on 4/17/19 at 11:41 a.m. included Certified Nursing Assistant (CNA) Staff A went to perform a blood sugar check on Resident #999. At 11:49 a.m., after having checked the resident's blood sugar, while carrying the glucometer, it came in contact with CNA Staff A's clothing. At 11:50 a.m. CNA Staff A returned to the medication room. CNA Staff A used the green top disinfectant (Clorox Healthcare Hydrogen Peroxide Disinfectant Wipes) to clean the glucometer by wiping it a few times. Less than a minute later CNA Staff A waved it around in the air to dry. The glucometer was wet for at least 30 seconds. 2. In an interview on 4/17/19 at 11:55 a.m., the Assistant Director of Nursing (ADON) said the green top (Hydrogen Peroxide) wipes were used to disinfect the glucometer. In an interview on 4/16/19 at 3:27 p.m., the Director of Nursing (DON) said the facility uses Clorox Healthcare Bleach Germicidal Wipes (blue top canister) to disinfect glucometers. 3. The Accu-Chek Inform II glucometer manufacturer's instructions state, on page 147 of the Operator's Manual (version 6.0) If dedicating blood glucose meters to a single patient is not possible, the meters must be properly cleaned and disinfected after every use following the guidelines given in this section. On page 149, the manufacturer's acceptable cleaning/disinfecting agents include Clorox Germicidal Wipes. The manual noted: Do not use any other cleaning or disinfecting solution. Using solutions other than Clorox Germicidal Wipes (EPA reg. no. -12) or Super Sani-Cloth Germicidal Disposable Wipes (EPA reg. no. 9480-4) could result in damage to the system components. (source: https://www.manualslib.com/manual/ 13/Accu-Chek-Inform-Ii.html?page=149#manual) Hydrogen Peroxide Disinfectant Wipes were not included as an acceptable product to use on this glucometer. 4. Review of(NAME)Health policy & procedures titled Glucose, Accu-Chek Inform II (Chapter M02, Tab 02, Policy #280, revised 6/18) revealed on page 10 under Infection Control part C, to Clean and disinfect with bleach germicidal wipe after every patient use. Allow wet solution to dwell on meter for 3 minutes to disinfect. Wipe dry after 3 minutes. 5. In an interview on 4/17/19 at 12:28 p.m., the Infection Preventionist said with the point-of-care shared devices, the staff have competencies upon hire and yearly thereafter. They take an online test with a quality control that is anyone certified to do glucometers, advanced CNAs, and licensed nurses. I do look at staff members to see if they are disinfecting it, following the protocol, and I do visual surveillance. She explained the staff are to use the blue top canister (Bleach Germicidal Wipes) disinfectant wipes to clean the glucometers. It is the policy that the glucometer is cleaned after use and before docking. If the glucometer was going from resident to resident, it would be cleaned in between each resident use. It would be cleaned with the blue top wipes with a 3 minute wet time.

Based on observation and staff interview the facility failed to maintain quality assurance regarding the cleaning and disinfecting of glucometers. The facility staff failed to follow the facility's policy and the manufacturer's recommendations for cleaning and disinfecting a glucometer for 1 resident (Resident #999) of 3 residents reviewed who. Glucometer competency does not specifically address disinfection and does not include demonstration of the procedure. Blood glucose meters can transmit blood-borne pathogens if these devices are contaminated with blood and are shared between users without effective cleaning, disinfecting, and appropriate infection control measures. The findings included: 1. Observation on 4/17/19 at 11:41 a.m. included Certified Nursing Assistant (CNA) Staff A went to perform a blood sugar check on Resident #999. At 11:49 a.m., after having checked the resident's blood sugar, while carrying the glucometer, it came in contact with CNA Staff A's clothing. At 11:50 a.m. CNA Staff A returned to the medication room. CNA Staff A used the green top disinfectant (Clorox Healthcare Hydrogen Peroxide Disinfectant Wipes) to clean the glucometer by wiping it a few times. Less than a minute later CNA Staff A waved it around in the air to dry. 2. In an interview on 4/17/19 at 11:55 a.m., the Assistant Director of Nursing (ADON) said the green top (Hydrogen Peroxide) wipes were used to disinfect the glucometer. 3. On 4/17/19 at 12:28 p.m., the Infection Control Preventionist said, With the point-of-care shared devices, the staff have competencies upon hire and yearly thereafter. They take an online test with a quality control that is anyone certified to do glucometers, advanced CNAs and licensed nurses. I do look at staff members to see if they are disinfecting it, following the protocol and I do visual surveillance. The Infection Control Preventionist stated No concerns had been identified with the cleaning process of the glucometers. The staff use the blue top disinfectant wipes to clean the glucometers. It is the policy that the glucometer is cleaned after use and before docking. Our policy is to clean after use. All staff have the policy that the glucometer is cleaned after use. If the glucometer was going from resident to resident, it would be cleaned in between each resident use. It would be cleaned with the blue top wipes with a 3 minute wet time. We changed from an alcohol based cleaner with a kill time of 2 minutes as a system and moved to a bleach wipe about 6 months ago. 4. Review of(NAME)Health policy & procedures titled Glucose, Accu-Chek Inform II (Chapter M02, Tab 02, Policy #280, revised 6/18) revealed on page 10 under Infection Control part C, to Clean and disinfect with bleach germicidal wipe after every patient use. Allow wet solution to dwell on meter for 3 minutes to disinfect. Wipe dry after 3 minutes. 5. Review of competency for (YEAR) Skills Validation for CNA Staff A dated 4/26/18 failed to document observations of the staff properly cleaning glucometers using the correct disinfectant and facility procedure. The glucometer competency is a written test with no visual demonstration of the procedure. 6. In an interview on 4/17/19 at 3:20 p.m., the Risk Manager said the Quality Assurance Performance Improvement team did not identify any infection control issues for the past year.

Based on staff interview and quality assurance record review, the facility failed to ensure the medical director or designee was included in the quality assessment and assurance (QAA) committee. The facility is required to include the medical director or designee in the QAA meetings at least quarterly. The findings included: 1. A review of the QAA meeting minutes and sign-in sheets for the past three months (1/26/17, 2/23/17, and 3/23/17) revealed the facility's medical director or designee was not included in these meetings. 2. On 4/13/17 at 3:00 p.m., the Quality Coordinator said the medical director and other physicians from this facility were not included in these meetings.

Based on observations and staff interviews, the facility failed to ensure safe water temperatures in 7 of 14 resident rooms and in the communal bathroom on the skilled nursing unit (SNU). The failure to maintain safe water temperatures increases the risk for serious burns and injury. The American Burn Association, Scald Injury Prevention (at http://www.ameriburn.org/Preven/ScaldInjuryEducator%27sGuide.pdf): Although scald burns can happen to anyone, young children, older adults and people with disabilities are the most likely to incur such injuries . The severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed . Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred . Scald injuries result in considerable pain, prolonged treatment, possible lifelong scarring, and even death. Excessive Hot Water Temperatures revised 2011 (at http://ahca.myflorida.com/MCHQ/Field_Ops/Protocols/General/Files/Hot_Water_Protocol.pdf): Typically, the regulations for most federally certified facilities do not include specific required hot water temperatures; however, the regulations address that the facility/provider must ensure the environmental safety of the persons receiving services. Water Temperature Time required for 3rd degree burn (degrees Fahrenheit(F)/Centigrade(C)) 124F/51C 3 minutes 120F/48C 5minutes 100F/37C safe temperature for bathing The findings included: 1. On 4/13/17 at 9:25 a.m. during a tour of the SNU, the hot water running out of the spigot in the bathroom sink of Room 3203 felt too hot. The Assistant Director of Nursing (ADON) who was present during the tour held her hand under the water and said she could not keep her hand under the water because it was too hot. The room was not occupied by a resident. On 4/13/17 at 9:26 a.m., the water temperature of the bathroom sink in Room 3204 was checked, and the ADON confirmed the temperature of the water was too hot. Resident #4, who was observed to have cognitive impairment, was not present in the room. At 9:27 a.m., the ADON said she had called environmental services to come and check the temperatures of the water in the rooms. On 4/13/17 at 9:36 a.m., the Plant Operations Tech III (POT III), Director of Plant Operations (DPO), and the Environmental Safety Coordinator (ESC) entered Room 3203. After confirming his digital thermometer was calibrated and allowing the water to flow for approximately 1 minute, the POT III tempted the hot water coming from the spigot of the bathroom sink which read 121.9 degrees F. On 4/13/17 at 9:42 a.m., the POT III entered Room 3204, and after allowing the water to flow for a minute, he tempted the hot water coming from the bathroom sink. He confirmed a temperature reading of 122.5 degrees F. On 4/13/17 at 9:48 a.m., the DPO tempted the hot water from the bathroom sink in the communal shower room. While the water was running, the DPO stated, I already know it's hot. I feel the heat coming off of the water. Using the same calibrated digital thermometer, the water temperature recorded as 122.8 degrees F. On 4/13/17 at approximately 10:00 a.m., a maintenance worker was observed taking the water temperature of the sink in the bathroom of Room 3214. After approximately a minute of the hot water turned on and flowing, the temperature of the water was measured at 119 degrees F. The worker also measured the hot water temperature at the bathroom sink in Room 3215 to be 117 degrees F after approximately 40 seconds. The Administrator was present while the temperatures were being taken. 2. On 4/13/17 at 10:00 a.m., in an interview with the ESC and DPO they said one of the 2 water heaters that supply the hospital patient population was down and would not be fixed until the following week. Because of this, they said they bumped up the temperature of the other water heater to overcompensate for the one in disrepair. The DPO said they increased the water temperature of the working heater between 120-125 degrees F. The DPO said they had not checked the temperatures of the water on the SNU after increasing the temperature of the water heater. He said they do not check the temperatures of the water on the SNU.

Based on record review, staff interview, and observation, the facility failed to ensure the medication error rate was less than 5%. The medication error rate was 3 of 31 opportunities or 9.7%. The errors resulted in one (Resident #2) having discomfort when receiving an injection and one (Resident #5) possibly receiving an incorrect dosage of a cough suppressant medication of 5 residents observed. The findings included: 1. On 4/13/17 at 2:00 p.m., Registered Nurse (RN) Staff B was observed applying [MEDICATION NAME] gel 2% (a topical anesthetic) to Resident #2's abdomen and immediately inject [MEDICATION NAME] (an anticoagulant) subcutaneously (under the skin) to the area where she had applied the [MEDICATION NAME] gel. Resident #2 grimaced when she was injected with the medication. The physician order [REDACTED]. On 4/13/17 at 2:30 p.m., RN Staff B said she was not aware of the special instructions for the medication. She said the medication is usually injected in the abdomen. RN Staff B verified she failed to wait one minute after applying the [MEDICATION NAME] before injecting the resident with [MEDICATION NAME]. On 4/13/17 at 2:35 p.m., the Assistant Director of Nursing (ADON) said the order had been changed on 4/12/17 because Resident #2 was having discomfort when she was being injected. The ADON verified [MEDICATION NAME] would not be effective without waiting for the medication to numb the area of the injection site. 2. On 4/12/17 at 12:41 p.m., RN Staff A was observed administering [MEDICATION NAME]/[MEDICATION NAME] extended release suspension (a combination cough suppressant medication) to Resident #5. RN Staff A poured the medication into a cup without shaking the bottle to mix the suspension. The administration instructions for [MEDICATION NAME]/[MEDICATION NAME] extended release oral suspension included, Shake well before using. (source: Drugs.com website at https://www.drugs.com/pro/[MEDICATION NAME]-and-[MEDICATION NAME].html) On 4/12/17 at 1:30 p.m., RN Staff A verified she did not shake the liquid suspension before administering the medication for Resident #5. RN Staff A verified there was no way to be sure Resident #5 had gotten the correct dosage of medication due to settling during storage.