| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 01C0001000 | (X3) Date Survey Completed 11/13/2019 |
| Name of Provider or Supplier Montgomery Surgical Center Llc | Street Address, City, State 470 Taylor Road, Montgomery, AL | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| Q0242 | INFECTION CONTROL PROGRAM CFR(s): 416.51(b) The ASC must maintain an ongoing program designed to prevent, control, and investigate infections and communicable diseases. In addition, the infection control and prevent program must include documentation that the ASC has considered, selected, and implemented nationally recognized infection control guidelines. This STANDARD is not met as evidenced by: Based on observation, review of the facility's policy, observation and staff interview it was determined, the facility staff failed to wash or sanitize hands and change gloves prior to performing blood sugar testing. This affected 1 of 1 pre-operative test procedure (blood sugar testing) observed including unsampled patient, and had the potential to affect all patients served. Findings include: Policy: Infection Control Plan Revised date: 4/19 Purpose: The infection control program is designed to prevent infection control occurrences and breaches: surgical site infections; and other health care - acquired infections. Procedures: A. 4. All personnel practice hand hygiene ... Prompt and frequent hand antisepsis should be performed: before and after patient contact. anytime there is a possibility that there is possibility that there has been contact with blood or other potentially infectious materials. anytime there is a possibility that there has been contact with blood or other potentially infectious materials B. 5. ... Items used during patient care should be cleaned and disinfected after each patient use. An observation of care was conducted on 11/12/19 at 10:15 AM to observe Employee Identifier (EI) # 3, Registered Nurse (RN) perform blood sugar stick for testing. The admission process was started by EI # 3, who explained to the unsampled patient that she/ he was going to start his/ her intravenous (IV) fluids before going to the surgery suite. With gloves on, EI # 3 inserted an angiocath to the unsampled patient's right hand. EI # 3 secured the IV line with tape. EI # 3 walked across to the Pre-operative Nursing Station and obtained a clean pipette from a clean container and a blood sugar strip from another clean container and proceeded to perform blood sugar testing. Without changing gloves, EI # 3 obtained a disinfectant wipe from a dispenser , cleaned the glucometer and placed glucometer back on its base, after the procedures were done. An interview was conducted on 11/13/19 at 8:15 AM with EI # 7, Infection Control Practitioner, who confirmed the staff should have changed gloves before starting any task, remove gloves after the task was performed/ or change gloves before starting another task. |