printed: 06/22/2018 department of health and ...patient use at the off-site medication clinic....

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

06/22/2018PRINTED:

FORM APPROVED

OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

(X3) DATE SURVEY

COMPLETED

NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

(X5)

COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

LOGANSPORT, IN 46947

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FOUR COUNTY COUNSELING CENTER

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A 0000

Bldg. 00

This visit was for a Federal recertification

survey

Facility Number: 005199

Survey Dates: 2/12/2018 to 2/15/2018

QA: 2/21/18

A 0000

482.25(b)(3)

UNUSABLE DRUGS NOT USED

§482.25(b)(3) - Outdated, mislabeled, or

otherwise unusable drugs and

biologicals must not be available for patient

use

A 0505

Bldg. 00

Based on document review, observation

and interview, the facility failed to ensure

that unusable drugs were not available for

patient use at the off-site Medication

Clinic.

Findings include:

1. Review of the hospital policy entitled,

"Medication Management-Pharmacy",

policy number 29.1.005S, indicated the

Medication Clinic outpatient stock and

sample drugs "shall be checked by the

A 0505 1. & 2. Director of Nursing and

Med Clinic Lead RN began

inspection of each medication

clinic office to monitor for any

outdated, expired medication left

in the office. This began the week

of 2/19/18. Any outdated

medication found was destroyed.

This will continue weekly for one

month, then monthly for 3

months, then quarterly. DON

responsible.

All medication clinic offices have

been checked and all expired

meds have been removed by

2/23/18.

03/31/2018 12:00:00AM

FORM CMS-2567(02-99) Previous Versions Obsolete

Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determined that

other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to

continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

_____________________________________________________________________________________________________Event ID: 5TSM11 Facility ID: 005199

TITLE

If continuation sheet of 37

(X6) DATE




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nursing staff on a regular basis to monitor

for expiration dates". Any expired

medication should be destroyed by the

nursing staff. This policy was last revised

on 08/01/2016.

2. Review of the hospital policy entitled,

"Stock Drugs-Acute Care Unit", policy

number 11.2.058CC, indicated "unused

or damaged drugs must be destroyed". A

nurse must destroy such drugs in the

presence of another nurse, or drugs may

be returned to the pharmacist for

destruction. This policy was last revised

on 06/08/2012.

3. Review of the pharmacy contract

entitled, "PROFESSIONAL SERVICES

AGREEMENT-EXHIBIT D-Pharmacy

Consultant Services", effective date

10/01/2012, indicated a consultant

pharmacist would be provided to "review

the issues related to storage, and perform

quarterly inspections of medication

storage".

4. During the facility tour of the F # 1

(Medication Clinic) on 02/13/2018 at

approximately 12:30 pm, with

administrative staff member A # 4

(Quality Assurance Associate), the

following patient's medications were

observed inside the refrigerator and/or

cabinet of the nurses office and marked

Director of Nursing and ACU

Lead Nurse will be responsible to

check this weekly for one month,

then monthly for 3 months, then

quarterly. DON responsible.

First check completed by ACU

Lead RN on 3/1/18

4. On the day of such 2/13/18, all

noted medications were

destroyed by DON and Med Clinic

Lead RN. An investigation was

started on 2/13/18 and was

completed on 2/23/18. It was

noted the written policy was not

clear so policy has been updated

to include disposal of all

discontinued medication. Upon

Board approval, this policy will be

sent out to all nurses via Relias to

ensure they understand the

policy. DON responsible.

2/13/18 All nursing staff report

never having used any of said

medication.

DON and Med Clinic Lead RN

shall .... See A505 above 2/13/18

5. 2/16/18 All nursing personnel

denied ever using these

medications. All nurses were See

above for training

policy/procedure. Shall be

completed with all nurses having

viewed and understand the policy

by 3/31/18. All nursing personnel

were reminded by email on 3/1/18

until policy is approved and out

for training.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5TSM11 Facility ID: 005199 If continuation sheet of 37




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EXTRA:

a. Three (3) boxes of Risperdal 25

milligram (mg) intramuscular (IM)

injections.

b. One (1) box of Risperdal 50 mg IM

injection.

c. One (1) box of Risperdal 50 mg IM

injection with an expiration date of

01/2018.

d. One (1) box of Abilify 300 mg IM

injection.

e. One (1) box of Abilify 400 mg IM

injection.

f. One (1) box of Aristada 662 mg IM

injection with an expiration date of

12/21/2016.

g. Five (5) boxes of Invega Sustenna

156 mg IM injections.

h. Two (2) boxes of Invega Sustenna

234 mg IM injections.

i. Four (4) boxes of Fluphenexine 125

mg IM injections.

5. On 02/13/2018 at approximately 12:45

pm with nursing staff member S # 2

(Registered Nurse), confirmed that F # 1

keeps the unused patients medications,

which has been discontinued and/or dose

has been changed, and marked them as

EXTRA. F # 1 then used the EXTRA

supply for patients that may have

received an order for that type of

medication.





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pm with administrative staff member A #

3 (Vice President of Quality

Compliance), confirmed that PH # 1

(Pharmacy) had not been to F # 1 in 2016

and 2017 to perform their quarterly

inspections.

482.27(a)

ADEQUACY OF LABORATORY SERVICES

The hospital must have laboratory services

available, either directly or through a

contractual agreement with a certified

laboratory that meets the requirements of

part 493 of this chapter.

A 0582

Bldg. 00

Based on document review, observation,

and staff interview, the hospital

laboratory services failed to meet the

requirements of 42 CFR 493 for two of

two glucometers observed.

Findings include:

1. Review of the hospital's CLIA

(Clinical Laboratory Improvement

Amendments) certificate indicated they

had a current "Certificate of Waiver."

2. Review of 42 CFR 493.15(e) read:

"Laboratories eligible for a certificate of

waiver must -- (1) Follow manufacturers'

instructions for performing the test..."

A 0582 3. Director of Nursing responsible

for new form titled Glucometer

Control/Test Strip Log. This form

is to be used daily when

glucometer is in use. On this

form, when a new control bottle is

opened, the date it was opened

goes on the form, the Lot number

and expiration date (3 months

from opening per manufactures

instructions or expiration date on

bottle -whichever is sooner) will

be listed. When test strips are

opened, the range values will be

listed of the form. One control

(normal, high, low) will be tested

every day it is in use. If out of

range, the other two will be tested

and both must be within range or

machine cannot be used. This

began on 2/15/18. DON

03/31/2018 12:00:00AM





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3. On 2-12-2018 at 2:20, while on tour

of the inpatient unit at the hospital's main

campus, a "Contour" glucometer was

observed in the "Med Room," available

for use. One opened bottle of test strips,

lot number "DW7JJ3B04C," expiration

date "2019-09-30" for the Contour

glucometer was observed near the

glucometer, available for use. An opened

low control, lot number "6BW1B03,"

expiration date "2018-08," normal

control, lot number "7BW2C07,"

expiration date "2019-04-30," and high

control, lot number "6BW3K02,"

expiration date "2018-07," were observed

near the glucometer, without the open

date indicated on the bottle.

4. On 2-13-2018 at 9:00 AM, while on

tour of off-site #2, a "Breeze 2"

glucometer was observed in the "Med

Room Office," available for use. An

open box of test strip discs, lot number

"1A6820AA," expiration date "2017-09,"

was observed near the glucometer,

available for use. A test strip disc, lot

number "1A6820AA," expiration date

"2017-09" was observed to be loaded into

the glucometer. A normal control, lot

number "5S2D73," expiration date

"2017-12," was observed near the

glucometer without the open date

indicated on the bottle.

responsible.

4. Removed all glucometers from

off site due to non-use in

outpatient setting on 2/19/18.

5. See Above. Policy changed to

meet the manufacturer

requirements of 2 new machine

purchased for the inpatient unit.

Breeze "Contour" machine no

longer in use. Abbott "Freestyle"

machines (2) purchased. New

policy reflects manufactures

instructions. DON responsible.

Policy changed. Awaiting Board

approval for policy 3/31/18.

5b. Manufacturer instructions will

be kept until bottle is empty or

expires. Nurses notified 3/1/18.

Audits will occur weekly. DON

responsible.

6. Policy changed. Policy

matches the manufacturers

instructions for 2 new

glucometers. Awaiting Board

approval 3/31/18.

7. See new procedure written on

#3. Director of Nursing

responsible for new form titled

Glucometer Control/Test Strip

Log. This form is to be used daily

when glucometer is in use. On

this form, when a new control

bottle is opened, the date it was

opened goes on the form, the Lot

number and expiration date (3

months from opening per

manufactures instructions or

expiration date on bottle

-whichever is sooner) will be

listed. When test strips are







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5. Review of manufacturers' instructions

for the glucometers indicated the

following:

a. Instructions for the "Contour"

glucometer, copyright 2011, read: "...for

the control solution do not use if it has

been six months (180 days) since you

first opened the bottle..." and "Compare

your control test result with the Normal

Control Range printed on the test strip

bottle label or on the bottom of the test

strip box. Note: Low and High control

range values can be found on the bottom

of the test strip box." and "If your control

test result is out of range, do not use your

meter for blood glucose testing until you

resolve the issue."

b. The facility did not have

manufacturer instructions for the Breeze

2 Normal Control and the Breeze 2 Test

Strips and it could not be determined if

the facility was following manufacturer

instructions for the Breeze 2 normal

control and test strips.

6. Review of policies/procedure titled:

"CLIA Waived Testing," policy number

"26.2.056C," last revised "11/29/17"

read: "Use a control solution (high, low,

or normal) to check the system before use

and daily thereafter..." and "Check

expiration date on the control solution; if

expired or solution has been open for







responsible.

8. See new procedure #3.

Director of Nursing responsible





















responsible.

9. Due to non use at off sites, all

glucometers were removed from

outpatient medication clinic

offices as of 2/26/18.













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thirty (30) days, dispose of." and "Check

control results with the manufacturer's

range for control results."

7. A handwritten, untitled, document

located on the counter top in the "Med

Room" at the hospital's main campus

read: "Low, Normal, High (sic) Ranges

can vary slightly with lot #s - Ranges are

located on bottom of Contour test strip

boxes. Record Levels for each new box

opened. * Contour test strip bottles

expires 6 mo after opened," and indicated

the control ranges for "test strip lot #

DW7JJ3804C" were: "Low 34-46,"

"Normal 108-149, " and "High 310-427."

The document did not indicated on what

date the test strips were opened, nor did it

include acceptable control ranges for

other test strip lot numbers.

8. Review of "Glucometer Accuracy

Checks" from 9-1-2017 to 2-12-2018

indicated low, normal, and high controls

were routinely performed at the hospital's

main campus for the Contour glucometer.

The document read: "Use at least two

solutions daily when glucometer is in use

to check accuracy - if inaccurate, write in

action taken..." It could not be

determined if control results were within

acceptable ranges, as the lot numbers and

dates of use of test strips used for the

control testing was not documented, nor















responsible.























responsible.

12. Since the glucometers have

not ever been used on a client in

the outpatient Med Clinic sites, all

glucometers were removed and





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was the open date for the current bottle of

test strips documented. Additionally,

controls were not performed on

10-25-2017.

9. Review of "Glucometer Accuracy

Checks" from 2-15-2017 to 2-12-2018

indicated only a normal control was

routinely performed at off-site #2. It

could not be determined if control results

were within acceptable ranges, as the lot

numbers and dates of use of test strip

discs used for the the control testing was

not documented, nor was the open date

for the current test strip discs

documented.

10. Review of inpatient glucometer test

reports indicated:

a. Patient #23 had glucometer testing

performed on 10-19-2017, 10-20-2017,

10-21-2017, 10-22-2017, 10-23-2017,

10-24-2017, and 10-25-2017 (when

controls were not performed), when it

could not be determined the controls

were within acceptable ranges.

b. Patient #30 had glucometer testing

performed on 11-3-2017, 11-4-2017,

11-5-2017, 11-6-2017, and 11-7-2027,

when it could not be determined controls

were within acceptable ranges.

11. In interview on 2-12-2017 at 2:20

PM:

no longer in use.





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a. Staff person L7 (Registered Nurse)

acknowledged the control bottles for the

Contour glucometer, in use at the

hospital's main campus, were not dated

when opened.

b. Staff person L2 (Lead Nurse)

acknowledged control for the Contour

glucometer must be discarded six months

after opening, per manufacturer's

instructions. L2 further acknowledged

the facility was unable to verify

glucometer control results were within

acceptable ranges, as the lot number and

dates of use, and control ranges were not

documented.


AM, staff person L8 (Licensed Practical

Nurse) acknowledged the glucometer test

strip discs and normal control solution in

use at off-site #2 were expired.

482.41

PHYSICAL ENVIRONMENT

The hospital must be constructed, arranged,

and maintained to ensure the safety of the

patient, and to provide facilities for diagnosis

and treatment and for special hospital

services appropriate to the needs of the

community.

A 0700

Bldg. 00

A 0700 Site plans were emailed to

Director of Facilities on 3/5/18

and hard copies will be delivered

on 3/6/18. Plans were at Arkor

03/31/2018 12:00:00AM





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A Life Safety Code Recertification

Survey was conducted by the Indiana

State Department of Health in accordance

with 42 CFR 482.41(b).

Survey Date: 02/14-15/18

Facility Number: 005199

At this Life Safety Code survey, Four

County Counseling Center was found not

in compliance with Requirements for

Participation in Medicare/Medicaid, 42

CFR Subpart 482.41(b), Life Safety from

Fire and the 2012 edition of the National

Fire Protection Association (NFPA) 101,

Life Safety Code (LSC).

Four County Counseling Center is

comprised of the main hospital in

Logansport, In (Building 01), and Market

Street (Building 02), and Stepping Stones

Clubhouse (Building 03).

Four County Counseling Center main

building, Building 01, a two story fully

sprinklered building with a construction

type that could be best determined by

observation and without plans as Type II

(000). The building with a fire alarm

system with partial smoke detection with

a fire alarm system with partial smoke

detection was surveyed with Chapter 19,

Existing Health Care occupancies.

Architects and Engineer. Director

of Facilities responsible.

Director of Facilities is in the

process of locating contractors to

address each area and to have

them visit on site and provide

bids.





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Building 01 provides overnight care.

Building 01 has a capacity of 15 and had

a census of 7 at the time of this survey.

Based on record review, observation and

interview, the facility was unable to

confirm the building construction type

conformed to health care construction

limitations, the facility to maintain 1 of 1

limited noncombustible rating (see tag

K161), the facility failed to maintain

protection of 1 of 1 stairway in

accordance of 19.3.1. LSC 19.3.1.1

requires where an enclosure is provided,

the construction shall have not less than a

1-hour fire resistance rating and the

facility failed to maintain protection of 2

of 3 ceiling barriers and 1 of 3 stairwells

in accordance of 19.3.1. LSC 19.3.1

requires protection of vertical openings

(see tag K311), the facility failed to

ensure 1 of 1 fire alarm systems was

maintained in accordance with 9.6.1.3.

LSC 9.6.1.3 requires a fire alarm system

to be installed, tested, and maintained

(see tag K345), the facility failed to

ensure the spray pattern for sprinkler

heads was not obstructed in 1 of 1 ACU

Room D, the facility failed to provide

sprinkler coverage for 1 of 1 ACU Water

Heater room, the facility failed to install

sprinkler head deflectors within 12 inches

of the ceiling in 1 of 1 "Old AGS Storage

room, the facility failed to maintain the





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ceiling construction in 1 of 1 Library in

accordance with 19.3.5.1. LSC 19.3.5.3

requires where required by 19.1.6,

buildings containing hospitals or limited

care facilities shall be protected

throughout by an approved, supervised

automatic sprinkler system (see tag

K351), the facility failed to ensure at

least 1 of 1 smoke/fire dampers in the

facility were inspected and provided

necessary maintenance at least every four

years (see tag K521), the facility failed to

ensure 1 of 1 elevator equipment room

was provided with smoke detection (see

tag K531), the facility failed to ensure 1

of 1 generator was accordance with

6.4.4.1.1.3. 2010 NFPA 110 8.4.2.3

states that diesel-powered EPS

installations that do not meet the

requirements of 8.4.2 shall be exercised

monthly with the available EPSS load

and shall be exercised annually with

supplemental loads at not less than 50

percent of the EPSS nameplate kW rating

for 30 continuous minutes and at not less

than 75 percent of the EPS nameplate kW

rating for 1 continuous hour for a total

test duration of not less than 1.5

continuous hours, the facility failed to

document the transfer time to the

alternate power source on the monthly

load tests for 12 of the past 12 months to

ensure the alternate power supply was

capable of supplying service within 10





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seconds, the facility failed to ensure a

written record of weekly inspections of

the starting batteries for the generator

was maintained for 52 of 52 weeks, the

facility failed to ensure a written record

of weekly inspections of the starting

batteries for the generator was maintained

for 52 of 52 weeks, the facility failed to

ensure 1 of 1 emergency diesel powered

generator was allowed a 5 minute cool

down period after a load test (see tag

K918), the facility failed to ensure 19 of

19 power cords was not used as a

substitute for fixed wiring (see tag

K920).

The cumulative effect of these systemic

problems resulted in the hospital's

inability to ensure that all locations from

which it provides services are

constructed, arranged and maintained to

ensure the provision of quality health

care in a safe environment.





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482.41(a)

MAINTENANCE OF PHYSICAL PLANT

The condition of the physical plant and the

overall hospital environment must be

developed and maintained in such a manner

that the safety and well-being of patients are

assured.

A 0701

Bldg. 00

Based on record review, observation and

interview, the facility was unable to

confirm the building construction type

conformed to health care construction

limitations in accordance with Table

19.1.6.1., the facility to maintain 1 of 1

limited noncombustible rating in

accordance with Table 19.1.6.1. This

deficient practice could affect all

occupants, the facility failed to maintain




and the construction shall have not less

than a 1-hour fire resistance rating. This






the construction shall have not less than a

1-hour fire resistance rating. This



protection of 2 of 3 ceiling barriers and 1

of 3 stairwells in accordance of 19.3.1.

LSC 19.3.1 requires protection of vertical

A 0701 1. Site plans were emailed to


and hard copies will be delivered

on 3/6/18. Plans were at Arkor

Architects and Engineer. 3/6/18

2. Director of Facilities is still

attempting to locate a contractor

to complete. Director of Facilities

responsible 3/31/18.

3. Director of Facilities will be

contacting Moss Engineering out

of Ft. Wayne, IN on 3/5/18 to set

up a site visit to fix problem

areas. Will need bid and

approval. Director of Facilities


4. Director of Facilities is still

attempting to locate contractor to

complete. Director of Facilities


5. On 3/7/18 Priority One came to

site and looked at dampers,

Director of Facilities responsible.

The agencies HVAC Company

will be coming this month to

address the dampers.

6. On 3/2/18 completed 30

minute Generator test. Will add

the 30 minute Generator test to

the monthly testing procedure.






03/31/2018 12:00:00AM





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openings. LSC 19.3.1 requires vertical

openings shall be enclosed or protected in

accordance with Section 8.6. LSC 8.6.1

requires every floor that separates stories

in a building shall be constructed as a

smoke barrier. LSC 19.3.1.1 requires

where an enclosure is provided, and the

construction shall have not less than a

1-hour fire resistance rating. This

deficient practice could affect staff only,

the facility failed to ensure at least 1 of 1

smoke/fire dampers in the facility were

inspected and provided necessary

maintenance at least every four years in

accordance with NFPA 90A. LSC 9.2.1

requires heating, ventilating and air

conditioning (HVAC) ductwork and

related equipment shall be in accordance

with NFPA 90A, Standard for the

Installation of Air-Conditioning and

Ventilating Systems. NFPA 90A, 2012

Edition, Section 5.4.8.1 states fire

dampers shall be maintained in

accordance with NFPA 80, Standard for

Fire Doors and Other Opening

Protectives. NFPA 80, 2010 Edition,

Section 19.4.1 states each damper shall

be tested and inspected 1 year after

installation. Section 19.4.1.1 states the

test and inspection frequency shall be

every 4 years except for hospitals where

the frequency is every 6 years. If the

damper is equipped with a fusible link,

the link shall be removed for testing to
















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ensure full closure and lock-in-place if so

equipped. The damper shall not be

blocked from closure in any way. All

inspections and testing shall be

documented, indicating the location of

the fire damper, date of inspection, name

of inspector and deficiencies discovered.

The documentation shall have a space to

indicate when and how the deficiencies

were corrected. This deficient practice

could affect all occupants, the facility

failed to ensure 1 of 1 generator was

accordance with 6.4.4.1.1.3. 2010 NFPA

110 8.4.2.3 states that diesel-powered

EPS installations that do not meet the

requirements of 8.4.2 shall be exercised

monthly with the available EPSS load

and shall be exercised annually with

supplemental loads at not less than 50

percent of the EPSS nameplate kW rating

for 30 continuous minutes and at not less

than 75 percent of the EPS nameplate kW

rating for 1 continuous hour for a total

test duration of not less than 1.5

continuous hours. This deficient practice

could affect all occupants, the facility

failed to document the transfer time to

the alternate power source on the

monthly load tests for 12 of the past 12

months to ensure the alternate power

supply was capable of supplying service

within 10 seconds. This deficient

practice could affect all residents, staff

and visitors, the facility failed to ensure a





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written record of weekly inspections of

the starting batteries for the generator

was maintained for 52 of 52 weeks.

Chapter 8.3.7 of NFPA 99 requires

storage batteries, including electrolyte

levels or battery voltage, used in

connection with essential electrical

systems shall be inspected weekly and

maintained in full compliance with

manufacturer's specifications. 8.3.7.2

requires defective batteries shall be

repaired or replaced immediately upon

discovery of defects. Chapter 6.4.4.2 of

NFPA 99 requires a written record of

inspection, performance, exercising

period, and repairs for the generator to be

regularly maintained and available for

inspection by the authority having

jurisdiction. This deficient practice could

affect all residents, staff and visitors, the

facility failed to ensure 1 of 1 emergency

diesel powered generator was allowed a 5

minute cool down period after a load test.

NFPA 110 8.4.5(4) requires a minimum

time delay of 5 minutes shall be provided

for unloaded running of the Emergency

Power Supply (EPS) prior to shut down.

This delay provides additional engine

cool down. This deficient practice could

affect all occupants.

Findings include:

1. Based on record review with the





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Director of Facilities on 02/14/18 at

11:43 a.m., the facility was unable to

provide construction site plan

documentation to review. Based on an

interview at the time of record review,

the Director of Facilities acknowledged

the aforementioned condition and

confirmed that the site plans were sent

out to be scanned.

2. Based on observation with the

Director of Facilities on 02/14/18 at 2:50

p.m., the "Old AGS Storage room" steel

support beams had some multiple spots

adding up to about one square foot where

the protective coating was removed.

Based on observation with the Director of

Facilities on 02/15/18 at 9:32 a.m. then

again at 9:37 a.m., the Maintenance

Storage room steel support beams had

some multiple spots adding up to about

one square foot where the protective

coating was removed. Then again, the

Boiler room steel support beams had

some multiple spots adding up to about

three square feet where the protective

coating was removed.

Based on an interview at the time of each

observation, the Director of Facilities

acknowledged each aforementioned

condition and confirmed that bare metal

was exposed.






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p.m., the 2nd floor South stairwell door

did not have a fire resistance rating.

Based on interview at the time of


confirmed no fire resistance rating could

be found.



between 1:43 p.m. and 2:35 p.m., the

following was discovered:

a) three separate three eighths inch gap

around piping in the ACS drywall ceiling

b) six separate quarter inch gaps inside

conduit in the Front Office Storage

drywall ceiling


Facilities on 02/15/18 at 9:21 a.m., the


c) three separate five eighths inch gaps

inside conduit in the 1st floor East

Stairwell

Based on interview at the time of each

observation, the Director of Facilities was

unaware of the penetrations and provided

the measurements.


Director of Facilities on 02/15/18, the

Director of Facilities stated that he did

not believe dampers were in the facility.

Based on observation at 9:39 a.m., the

Maintenance room contained a damper in





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the HVAC vent.



10:24 a.m., the monthly testing

documentation did not specify a load

percentage. Based on an interview at the

time of record review, the Director of

Facilities confirmed no load bank test

documentation was available to review.



10:24 a.m., the monthly Generator Load

Tests lacked the generator's transfer time

from normal power to emergency power.

Based on interview at the time of record

review, the Director of Facilities

acknowledged the lack of documentation.



10:24 a.m., no weekly documentation

was not available for review. Based on an



the lack of documentation.



10:24 a.m., the generator log form

documented the generator was tested

monthly for at least 30 minutes under

load, however, there was no





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documentation on the form that showed

the generator had a cool down time

following its load test. Based on



the lack of documentation.

482.41(b)

LIFE SAFETY FROM FIRE

Life Safety from Fire

A 0709

Bldg. 00

Based on record review and interview,

the facility failed to ensure 1 of 1 fire

alarm systems was maintained in


requires a fire alarm system to be

installed, tested, and maintained in

accordance with NFPA 70, National

Electrical Code and NFPA 72, National

Fire Alarm Code. NFPA 72, 14.4.5

Testing Frequencies. NFPA 72,

14.4.5.3.1 states sensitivity shall be

A 0709 1. On 3/7/18 Priority One will be

providing documentation to

Director of Facilities of smoke

detector sensitivities test. Director

of Facilities responsible.

2. Contractor will be on site

3/8/18 to acquire BID for repair,

30 days to repair. Director of

Facilities responsible 3/31/18.



30 days to repair, Director of




03/31/2018 12:00:00AM





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checked within 1 year after installation.

NFPA 72, 14.4.5.3.2 states sensitivity

shall be checked every alternate year

thereafter unless otherwise permitted by

compliance with 14.4.5.3.3. This


occupants, the facility failed to ensure the

spray pattern for sprinkler heads was not

obstructed in 1 of 1 ACU Room D in

accordance with 19.3.5.1. NFPA 13,

2010 edition, Section 8.5.5.1, states

sprinklers shall be located so as to

minimize obstructions to discharge as

defined in 8.5.5.2. and 8.5.5.3 or

additional sprinklers shall be provided to

ensure adequate coverage of the hazard.

Section 8.5.5.2 and 8.5.5.3 do not permit

continuous or noncontinuous obstructions

less than or equal to 18 in. below the

sprinkler deflector that prevent the

pattern from fully developing. This

deficient practice could affect staff and at

least 1 patient, the facility failed to

provide sprinkler coverage for 1 of 1

ACU Water Heater room in accordance

with 19.3.5.1. This deficient practice

could affect staff only, the facility failed

to install sprinkler head deflectors within

12 inches of the ceiling in 1 of 1 "Old

AGS Storage room." NFPA 13, 2010

Edition, Section 8.6.4.1.1.1 under

unobstructed construction, the distance

between the sprinkler deflector and the

ceiling shall be a minimum of 1 inch and











7. Documentation of all

appliances are to be plugged in to

wall sockets, not surge protector

and/or extension cords will be put

into policy. Director of Facilities

responsible. Awaiting Board

approval 3/31/18.





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a maximum of 12 inches throughout the

area of coverage of the sprinkler. This

deficient practice could affect staff only,

the facility failed to maintain the ceiling

construction in 1 of 1 Library in


requires where required by 19.1.6,

buildings containing hospitals or limited

care facilities shall be protected

throughout by an approved, supervised

automatic sprinkler system in accordance

with Section 9.7. Section 9.7 indicates

that automatic sprinkler system requires

shall be in accordance with NFPA 13.

NFPA 13, 2010 edition, Section 6.2.7

states plates, escutcheons, or other

devices used to cover the annular space

around a sprinkler shall be metallic, or

shall be listed for use around a sprinkler.

This deficient practice could affect staff

only, the facility failed to ensure 1 of 1

elevator equipment room was provided

with smoke detection in accordance with

ASME/ANSI A17.3. This deficient

practice could affect staff only, the

facility failed to ensure 19 of 19 power

cords was not used as a substitute for

fixed wiring according to 33.2.5.1. LSC

33.2.5.1 states utilities shall comply with

Section 9.1. LSC 9.1.2 requires electrical

wiring and equipment shall be in

accordance with NFPA 70, National

Electrical Code. NFPA 70, 2011 Edition,

Article 400.8 requires that, unless





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specifically permitted, flexible cords and

cables shall not be used as a substitute for

fixed wiring of a structure. This deficient

practice could affect all occupants.

Findings include:



p.m., fire alarm smoke detector

sensitivity test was not available for

review. Based on interview at the time of

record review, the Director of Facilities

acknowledged the aforementioned

condition and confirmed no other

documentation was available for review.



p.m., ACU Room D sprinkler head

deflector was higher than the drywall.




condition and confirmed the sprinkler

head was obstructed.



p.m., the ACU Water Heater room did

not have sprinkler protection installed at

this fully automatic sprinklered building.


observation, the Maintenance Technician





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#1 confirmed the room did not have

sprinkler protection installed.



p.m., the "Old AGS Storage room"

contains a sprinkler head deflector was

estimated at 48 inches from the ceiling.




condition and provided the estimated

measurement.



p.m., the Library had a missing

escutcheon. Based on interview at the

time of observation, the Director of

Facilities acknowledged the missing

escutcheon.



a.m., the elevator equipment room

contained 1 sprinkler head, a heat

detector but no smoke detector. Based on

interview at the time of observation, the

Director of Facilities confirmed no

smoke detector was present in the

elevator equipment room.







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between 1:40 p.m. and 2:27 p.m., the


a) a surge protector was powering a

coffee pot in the "CSS Half wall"

b) an extension cord was powering a

microwave in the ACU Case

Management office

c) a surge protector was powering a

coffee pot, toaster, and microwave in the

ACU Rounds room

d) a surge protector was powering

another surge protector powering a

refrigerator and a microwave in office

room 220

e) a surge protector was powering a

microwave and a refrigerator in office

room 213


Facilities on 02/15/18 between 9:21 a.m.

and 10:15 a.m., the following was

discovered:

f) a surge protector was powering another

surge protector powering computer

components in the "unmanned IT office"

g) four separate surge protector was

powering another surge protector in the

"MF office"

h) a surge protector was powering a

microwave in the IT room

i) a surge protector was powering a

refrigerator in the Transportation room.

Additionally, a surge protector was

powering a microwave and a coffee pot






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observation, the Director of Facilities was

unaware of regulation and acknowledged

each interconnected surge protector.

482.41(b)(6)

DISPOSAL OF TRASH

The hospital must have procedures for the

proper routine storage and prompt disposal

of trash.

A 0713

Bldg. 00

Based on document review, observation,

and interview, the hospital failed to

properly store biohazard waste in two of

two instances.

Findings include:

1. Review of policy/procedure titled:

"Infectious Waste Handling And

Disposal," policy number "C38.1.002,"

effective "8-27-99," read: "Infectious

waste will be segregated in containers

with a biohazard symbol, will not be

compacted, and will be handled from

point of origin to final disposal in

accordance with the ISBH rule."

2. 410 IAC 1-3-25 reads: "If infectious

A 0713 On 2/16/18 the Director of

Nursing and Director of

Facilities went to all facilities to

ensure that all biohazard waste

were clearly marked and if

needed to be relocated to

locked secure areas that are

not accessible to the public

and/or clients were done so. All

biohazard containers have

been marked and relocated as

of 3/20/18. Director of Facilities

responsible.

The location of the biohazard

containers will be added to the

maintenance monthly walk thru

to ensure that the containers

are maintained behind locked

secure areas that are not

accessible to the public and/or

03/31/2018 12:00:00AM





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waste is stored prior to final disposal, all

persons subject to this rule shall: (1)

store infectious waste in a secure area

that: (A) is locked or otherwise secured

to eliminate access by or exposure to the

general public...(C) has a prominently

displayed biohazard symbol..."

3. On 2-13-2018 at 9:45 AM, while on

tour of off-site #2, biohazard waste was

observed to be stored in an unlocked staff

restroom, without a biohazard symbol

displayed, accessible by a public hallway.

4. On 2-13-2018 at 11:05 AM, biohazard

waste was observed to be stored in the

patient exam room at the main hospital

campus.

5. In interview on 2-13-2018:

a. At 9:55 AM, staff person L6

(Medical Assistant) indicated full sharps

containers are placed in biohazard

containers in the staff restroom at off-site

#2 for storage prior to removal for final

disposal by the contracted biohazard

waste handler.

b. At 11:05 AM, staff person L1

(Director of Nursing) indicated biohazard

waste is stored in a biohazard waste

container in the patient exam room where

patients receive medical exams.

clients. Director of Facilities


The Director of Facilities was

responsible for #1 which was

completed on 2/16/18 and #2

the Director of Facilities will be

responsible to maintain 3/31/18





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482.41(c)(4)

VENTILATION, LIGHT, TEMPERATURE

CONTROLS

There must be proper ventilation, light, and

temperature controls in pharmaceutical,

food preparation, and other appropriate

areas.

A 0726

Bldg. 00

Based on document review and

interview, the hospital failed to ensure

proper temperature controls for two of

four pharmaceutical and five of five food

refrigerators reviewed.

Findings include:

1. Review of policies and procedures

indicated:

a. A policy/procedure titled:

"Medication Management," policy

number "29.1.005S," last revised

"8-1-16," read: "Acute Care

Unit...Refrigerator temperature is

maintained between 36-46 F." and

"Medication Clinic...All medications

needing refrigeration are maintained in a

refrigerator with temperatures between

36-46 degrees Fahrenheit."

b. A policy/procedure titled:

"Refrigerator/Freezers," policy number

"S38.1.011A," last revised "3-12-09,"

read: "The temperature range of all

refrigerators used for clinical purposes is

to be maintained between 35° and 42° F."

A 0726 1a. All policies will be changed

and forms to match the changes.

All refrigerators with medication

need to be kept at 36 - 46

degrees F. One policy got

changed but the other did not

Policy S38.1.011A will be

changed to meet this and match

MM29.1.005S. The form will

match these temps and be placed

on all the med refrigerators. DON


1b, c, d. All policies will be

changed to match as per State

Dept of Health, refrigerated food

needs to be kept between 35 and

41 degrees F. S38.1.013B will be

changed to meet the standard.

Form for food refrigerators will

match. DON responsible 3/31/18.


changed and forms to match the

changes. All refrigerators with

medication need to be kept at 36

- 46 degrees F. One policy got







responsible 3/31/18. All policies

03/31/2018 12:00:00AM





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c. A policy/procedure titled: "Kitchen

Supplies," policy number "11.2.045C,"

last revised "11.3-9-15," read: "All food

item (sic) requiring refrigeration shall be

kept between 35-45 degrees."

d. A policy/procedure titled:

"Refrigerator Temperature for Food

Storage," policy number "31.1.029,"

origination date "3-5-15," read: "Per the

State Department of Health, refrigerated

food requires to be maintained between

35-45 degrees Fahrenheit."

e. A policy/procedure titled:

"Management Plan for Food Safety,"

policy number "S38.1.013B," last revised

"10/15/14," read: "Ensure appropriate

temperatures are met as evidenced by 35

to 42 degrees temperature in refrigerators

for food storage, 0 degrees or below in

freezers for food storage..."

2. Review of 410 IAC 7-24, Sanitary

Standards for the Operation of Retail

Food Establishments, section 187 (a)

read: "...potentially hazardous food shall

be maintained as follows...at forty-one

(41) degrees Fahrenheit or less."

3. Review of "Refrigerator/Freezer

Temperature Monitor" logs for

medication refrigerators indicated the

"safe range" was 35 degrees Fahrenheit

(F) to 44 F. Temperatures were not

within acceptable limits as follows:

will be changed to match as per

State Dept of Health, refrigerated

food needs to be kept between 35

and 41 degrees F. S38.1.013B

will be changed to meet the

standard. Form for food

refrigerators will match. DON













responsible 3/31/18. All policies

will be changed to match as per

State Dept of Health, refrigerated

food needs to be kept between 35

and 41 degrees F. S38.1.013B

will be changed to meet the

standard. Form for food

refrigerators will match. DON


3. See 1a. All policies will be












4. These temperatures are out of

range for the new information





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a. For the main hospital campus, the

medication room refrigerator (med room

ACU) temperatures were documented as

"34 or less" on the following dates:

12-2-2017; 12-6-2017; 12-13-2017;

12-23-2017; 12-29-2017; 1-5-2018; and

1-13-2018.

b. For off-site #1, the medication

refrigerator (med fridge) temperatures

were documented as "34 or less" on the

following dates: 11-6-2017; 12-27-2017;

and 1-15-2018; and temperatures were

documented as "45 or more" on

12-20-2017.

4. Review of "Refrigerator/Freezer

Temperature Monitor" logs for food

refrigerators read: "If temperature is not

in safe range for (3) consecutive days

notify Infection Control" and indicated

the "safe range" was 35 F to 44 F.

Temperatures were not within acceptable

limits (per 410 IAC 7-24, section 187(a))

as follows:

a. For the main hospital campus:

1. The acute care unit refrigerator

(client): 11-9-2017 (43 F); 11-13-2017

(42 F); 11-16-2017 (42 F); 11-28-2017

(42 F); 12-15-2017 (42 F); 12-29-2017

(42 F); and 1-7-2018 (42 F)

2. The staff food refrigerator (staff):

12-2-2017 (42 F); 12-3-2017 (43 F);

12-4-2017 (42 F); 12-5-2017 (42 F);

1-1-2018 (44 F); 1-2-2018 (44 F);

given that food needs to be at 41

degrees F or less. However, most

of these temps met our current

policy and practice.

New policies will be put in place

where food refrigerator temps will

be kept between 35 and 41

degrees F with a new form that

matches this. DON responsible

3/31/18.

5. Policies to be changed, along

with forms for monitoring to

match the 35 to 41 degrees F

standard. DON responsible

3/31/18.

6. Historically, ISDH never

wanted to look at staff

refrigerators, only those where

clients are affected, so no

infection control report had been

sent for the staff refrigerator.

Managers and nursing personnel

reminded to notify Infection

Control. It is also listed on the

bottom of the temperature log

form. DON responsible 3/31/18.

7. A Medication Log will be kept in

front of each medication

refrigerator. As medications are

put in the refrigerator the will be

signed in and as they are

removed, they will be signed out.

DON responsible 3/31/18.





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1-4-2018 (43 F); 1-21-2018 (documented

as "45 or more"); 1-22-2018 (documented

as "45 or more"); 1-23-2018 (documented

as "45 or more"); 1-28-2018 (43 F);

1-29-2017 (43 F); and 1-30-2018 (43 F).

3. The kitchenette refrigerator:

11-1-2017 (42 F); 11-2-107 (43 F);

11-3-2017 (42 F); 11-6-2017 (42 F);

11-13-2017 (42 F); 11-14-2017 42 F);

11-15-2017 (42 F); 11-20-217 (42 F);

11-28-2017 (42 F; 11-29-2017 (42 F);

11-30-2017 (42 F); 12-1-2017 (43 F);

12-5-2017 (43 F); 12-14-2017 (42 F);

12-19-2017 (43 F); 12-20-2017 (42 F);

12-26-2017 (42 F); 12-27-2017 (42 F);

1-9-2018 (43 F); 1-18-2018 (42 F);

1-22-2018 (43 F); 1-30-2018 (42 F); and

1-31-2018 (42 F).

b. For off-site #1:

1. The west kitchen food

refrigerator (west kitchen): 11-4-2107

(44 F); 11-10-2017 (43 F); 11-11-2017

(42 F); 11-172017 (44 F); 11-18-2017

(documented as "45 or more");

11-19-2017 (44 F); 11-28-2017 (44 F);

12-2-017 (documented as "45 or more");

12-3-2017 (documented as "45 or more");

12-7-2017 (42 F); 12-8-2017 (42 F);

12-14-2017 (documented as "45 or

more"); 12-28-2018 (documented as "45

or more"); 12-23-2017 (43 F);

12-24-2017 (43 F); 12-25-2017 (42 F);

12-31-2017 (43 F); 1-9-2018 (43 F);

1-15-2018 (43 F); 1-16-2018 (43 F);





06/22/2018PRINTED:

FORM APPROVED

OMB NO. 0938-0391




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B. WING

(X3) DATE SURVEY

COMPLETED


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1-17-2018 (43 F); and 1-21-2018 (42 F).

2. The east kitchen food

refrigerator (east kitchen): 11-4-2017 (43

F); 11-15-2017 (42 F); 11-17-2017 (44

F); 11-18-2017 (43 F); 11-29-2017 (42

F); 11-20-2017 (42 F); 11-21-2017 (44

F); 11-22-2017 (42 F); 11-26-2017

(documented as "45 or more");

11-27-2017 44 F); 11-28-2017 (44 F);

12-2-2017 (44 F); 12-2-2017 (42 F);

12-7-2017 (44 F); 12-9-2017 (42 F);

12-11-2017 (43 F); 12-12-2017 (44 F);

12-13-2017 (documented as "45 or

more"); 12-14-2017 (documented as 45

or more"); 12-15-2017 (44 F);

12-28-2017 (43 F); 12-31-2017 (42 F);

1-4-2018 (42 F); 1-9-2018 (documented

as "45 or more"); 1-15-2018 (42 F);

1-21-2018 (44 F); 1-25-2018 (42 F); and

1-31-2018 (43 F).


PM, staff member L1 (Director of

Nursing) acknowledged there was a

discrepancy with policies and procedures

for medication and food refrigerator

temperature requirements. L1 indicated

the correct temperature range for

medication and food refrigerators is 35 F

- 44 F.

6. On 2-13-2018 at 3:30 PM, staff

member L2 (Lead Nurse) indicated there

was no infection control report generated





06/22/2018PRINTED:

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for the staff food refrigerator at the main

campus when the temperature was out of

range (per policy) for three consecutive

dates (1-21-2018; 1-22-2018; and

1-23-2018).

7. On 2-14-2018 at 9:30 AM, staff

member L1 indicated the hospital was

unable to determine what medications

were in the medication refrigerators when

the temperatures were out of range.

482.42(a)(1)

INFECTION CONTROL PROGRAM

The infection control officer or officers must

develop a system for identifying, reporting,

investigating, and controlling infections and

communicable diseases of patients and

personnel.

A 0749

Bldg. 00

Based on document review, observation

and interview, the hospital failed to

develop a system for controlling

infections of patients in three instances.

Findings include:

1. Review of "Infection Prevention

During Blood Glucose Monitoring and

Insulin Administration," published by the

Centers for Disease Control and

Prevention (CDC), and last updated on

June 8, 2017, read: "Recommended

A 0749 1. one or more Off Site Clinics

had a fingerstick device that more

that one person could use. These

have been removed from all sites

as of 2/26/18. The Inpatient Unit

only uses individual lancets.

DON responsible.

3. Bayer Breeze 2 meters were

removed from premise in the

Offsite Clinic as of 2/26/18. DON

responsible.




responsible.

5. All glucometers have been

03/02/2018 12:00:00AM





06/22/2018PRINTED:

FORM APPROVED

OMB NO. 0938-0391




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B. WING

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Practices for Preventing Bloodborne

Pathogen Transmission during Blood

Glucose Monitoring and Insulin

Administration Healthcare

Settings...Restrict use of fingerstick

devices to individual persons. They

should never be used for more than one

person."

2. Review of policy/procedure titled:

"CLIA Waived Testing, General

Clinical" policy number "26.2.056C," last

revised "11/29/17" read: "Follow

manufacturer's direction for inserting

lancet into lancet holder..." and

"Different types of meters have very

different cleaning needs...Follow

manufacturer's directions."

3. Review of manufacturer's instructions

for the Breeze 2 glucometer, copyright

unknown read: "Your Breeze 2 meter

can be cleaned using a moist (not wet)

lint-free tissue with a mild detergent or

disinfection solution (1 part bleach mixed

with 9 parts water). Do not use alcohol."

4. Review of the manufacturer's

directions "Caring for the System", for

the Bayer Contour glucometer indicated

the meter should be cleaned using a moist

(not-wet) lint-free tissue with a mild

detergent or disinfectant solution, such as

one (1) part bleach mixed with nine (9)

removed from Outpatient Med

Clinic Offices as of 2/26/18. The

only glucometers are now on the

Inpatient Unit. DON responsible.




responsible.

7. All Off Site Clinic glucometers

have been removed. Inpatient

glucometer was changed from

Contour to Freestyle from Abbott.

All nurses were inserviced via

video made by manufacturer that

included how to use and how to

clean. Materials present on

Inpatient Unit to clean using

manufacturers instructions. DON

responsible.

8. See #7. All Off Site Clinic

glucometers have been removed.

Inpatient glucometer was

changed from Contour to

Freestyle from Abbott. All nurses

were inserviced via video made

by manufacturer that included

how to use and how to clean.

Materials present on Inpatient

Unit to clean using manufacturers

instructions. DON responsible.





06/22/2018PRINTED:

FORM APPROVED

OMB NO. 0938-0391




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B. WING

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parts water then wipe dry with a lint-free

tissue after cleaning.

5. On 2-13-2018 at 9:00 AM, while on

tour of off-site two, a multi-use lancet

device was observed in the "med room"

drawer with a Breeze 2 glucometer. The

lancet device had a dried red substance,

resembling dried blood, on the end of it.


PM with administrative staff member A #

1 (Director of Nursing), confirmed that

the nursing staff at off-site one were

using alcohol wipes to clean the Bayer

Contour glucometer


AM, staff person L8 (Licensed Practical

Nurse) acknowledged the lancet device

was used to obtain blood samples for

glucometer testing on multiple patients

and appeared to have dried blood on the

end of it. L8 further indicated the lancet

device and glucometer were cleaned with

alcohol preparation pads in between use

with different patients. On the same date

at 9:28 AM, L8 acknowledged the

manufacturer's instructions prohibit the

use of alcohol as a cleaning agent for the

glucometer.


PM, with administrative staff member A





06/22/2018PRINTED:

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OMB NO. 0938-0391




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# 1, confirmed the nursing staff was not

in-serviced on how to properly clean the

glucometer.


printed: 06/22/2018 department of health and ...patient use at the off-site medication clinic....

Documents