Jasper General Hospital

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 48927 Based on observation, staff interview, manufacturer guideline review, policy and procedure reviews, the facility failed to maintain infection control method for staff performing a venipuncture procedure and for cleaning/disinfecting/and monitoring a glucose monitor on two (2) of four (4) days of survey; Registered Nurse (RN) #1 and Phlebotomist #1. Findings Include: During observation of the glucometer docking station located at Nursing Station #1 with RN #1 on 03/26/2025 at 11:11 a.m. revealed the glucometer had unknown brown substance on the surface of the monitor and the RN #1 cleansed the monitor with an alcohol pad instead of Sani-cloth wipes according to manufacturer guidelines. During an observation at Nursing Station #1 with R.N. # 1 the Blood Glucose Monitor control at 11:14 a.m. on 03/26/2025 reveals the Professional Monitoring Blood Glucose System Control Solution Level one, Lot # 2BC1B59 with expiration date 06/30/2024 and Control Solution Level 1, Lot # 2BC1B57 with expiration date 05/31/2024, further reveals bottles have no open date recorded on the bottles and no control bottle solutions located of Level two (2) or three (3) glucose monitor controls solutions per manufacturer guidelines. During observation on 03/26/2025 at 1:37 p.m. of Phlebotomist #1 performing a venipuncture on patient #16, the Phlebotomist #1 failed to perform universal precautions for infection control as evidence by not maintaining aseptic surface area, not discarding soiled gloves. During an Interview with RN #1 on 03/26/2025 at 11:14 a.m. RN #1 confirmed she did not follow recommended manufacturer guidelines for cleaning/disinfecting the glucose monitor and further confirms the two (2) bottles of Level one (1) glucometer control solutions were the same control, both were expired and not labeled with open date. During an interview with the Director of Nursing (DON) on 03/26/2025 at 11:24 a.m. confirmed the two (2) bottles of Level one (1) glucometer control solutions were the same control, both were expired and not labeled with open date. During an Interview with the Director of Nursing (DON) on 03/26/2025 at 1:50 p.m. confirmed, staff members receive Infection Control Prevention education upon hire and annually. Review of the facility’s policy, “Blood Glucose Monitoring” dated 09/29/2023 reveals, “ ...6. Control checks on glucometers must be performed as per manufacturer’s instructions ...”. Review of “TRUE METRIX PRO Professional Monitoring Blood Glucose System Owner’s Booklet” 2024, reveals “ ...Perform Control tests with more than one level of control solution ...Three levels ...are available for Control Tests ...Control Solution Level one (1), two (2) or three (3) ...recommend testing at least two (2) levels of control solution ...Do not use control solution or test strips if expiration dates have passed .... Discard expired products and use new products ... ...To Clean and Disinfect the meter after every use ...with only Super Sani-cloth wipes (or any disinfectant product with the EPA reg. no. of 9480-4), rub the entire outside of the meter ...discard used wipes ...”. Review of facility’s policy and procedure, Specimen collection: Venipuncture, dated 02/07/2020 reveals, “ ...Use universal precautions ...wash your hands ...after you remove and discard your gloves ...PRACTICE UNIVERSAL (STANDARD) PRECAUTIONS ...”. During the exit conference on 03/27/2025 at 3:30 p.m. survey findings were discussed with Chief Executive Officer, Director of Nursing, Assistant Director of Nursing, Registered Nurse, Minimum Data Set (MDS), Human Resource Director, Dietary Manager, Licensed Social Worker, Rehabilitation Manager, Housekeeping/Laundry Service Director, Clinical Laboratories Manager, Radiology Manager, Medical Records Manager and no further documentation was submitted for review.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 48927 Based on observation, staff interview, manufacturer guideline review, policy and procedure reviews, the facility failed to maintain infection control method for staff performing a venipuncture procedure and for cleaning/disinfecting/and monitoring a glucose monitor on two (2) of four (4) days of survey; Registered Nurse (RN) #1 and Phlebotomist #1. Findings Include: During observation of the glucometer docking station located at Nursing Station #1 with RN #1 on 03/26/2025 at 11:11 a.m. revealed the glucometer had unknown brown substance on the surface of the monitor and the RN #1 cleansed the monitor with an alcohol pad instead of Sani-cloth wipes according to manufacturer guidelines. During an observation at Nursing Station #1 with R.N. # 1 the Blood Glucose Monitor control at 11:14 a.m. on 03/26/2025 reveals the Professional Monitoring Blood Glucose System Control Solution Level one, Lot # 2BC1B59 with expiration date 06/30/2024 and Control Solution Level 1, Lot # 2BC1B57 with expiration date 05/31/2024, further reveals bottles have no open date recorded on the bottles and no control bottle solutions located of Level two (2) or three (3) glucose monitor controls solutions per manufacturer guidelines. During observation on 03/26/2025 at 1:37 p.m. of Phlebotomist #1 performing a venipuncture on patient #16, the Phlebotomist #1 failed to perform universal precautions for infection control as evidence by not maintaining aseptic surface area, not discarding soiled gloves. During an Interview with RN #1 on 03/26/2025 at 11:14 a.m. RN #1 confirmed she did not follow recommended manufacturer guidelines for cleaning/disinfecting the glucose monitor and further confirms the two (2) bottles of Level one (1) glucometer control solutions were the same control, both were expired and not labeled with open date. During an interview with the Director of Nursing (DON) on 03/26/2025 at 11:24 a.m. confirmed the two (2) bottles of Level one (1) glucometer control solutions were the same control, both were expired and not labeled with open date. During an Interview with the Director of Nursing (DON) on 03/26/2025 at 1:50 p.m. confirmed, staff members receive Infection Control Prevention education upon hire and annually. Review of the facility’s policy, “Blood Glucose Monitoring” dated 09/29/2023 reveals, “ ...6. Control checks on glucometers must be performed as per manufacturer’s instructions ...”. Review of “TRUE METRIX PRO Professional Monitoring Blood Glucose System Owner’s Booklet” 2024, reveals “ ...Perform Control tests with more than one level of control solution ...Three levels ...are available for Control Tests ...Control Solution Level one (1), two (2) or three (3) ...recommend testing at least two (2) levels of control solution ...Do not use control solution or test strips if expiration dates have passed .... Discard expired products and use new products ... ...To Clean and Disinfect the meter after every use ...with only Super Sani-cloth wipes (or any disinfectant product with the EPA reg. no. of 9480-4), rub the entire outside of the meter ...discard used wipes ...”. Review of facility’s policy and procedure, Specimen collection: Venipuncture, dated 02/07/2020 reveals, “ ...Use universal precautions ...wash your hands ...after you remove and discard your gloves ...PRACTICE UNIVERSAL (STANDARD) PRECAUTIONS ...”. During the exit conference on 03/27/2025 at 3:30 p.m. survey findings were discussed with Chief Executive Officer, Director of Nursing, Assistant Director of Nursing, Registered Nurse, Minimum Data Set (MDS), Human Resource Director, Dietary Manager, Licensed Social Worker, Rehabilitation Manager, Housekeeping/Laundry Service Director, Clinical Laboratories Manager, Radiology Manager, Medical Records Manager and no further documentation was submitted for review.”