Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 530025 (X3) Date Survey Completed 11/03/2011
Name of Provider or Supplier Ivinson Memorial Hospital Street Address, City, State 255 N 30th, Laramie, WY
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)
A0749 INFECTION CONTROL OFFICER RESPONSIBILITIES
CFR(s): 482.42(a)(1)

The infection control officer or officers must develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.


This STANDARD is not met as evidenced by:
Based on observation, staff interview, and review of quality assurance data, information from the CDC, and policies and procedures, the facility failed to develop, implement, and evaluate a hospital-wide infection control program that utilized real-time data. In addition, the facility failed to develop policies and procedures to mitigate risks contributing to healthcare-associated infections potentially transmitted by glucometers. Finally, the facility failed to ensure the cleanliness of devices used in medication administration. The findings were: 1. Interview with the infection control practitioner (ICP) and review of quality assurance data on 11/3/11 at 9:45 AM revealed the infection control committee met quarterly but reviewed data that was several months old. Perusal of the graphs produced by the ICP showed the latest data available for review at the next infection control meeting in November was from June 2011. Although there was a mechanism in place for notifying the ICP if an infectious outbreak occurred, there was no evidence real-time data would be available for review by the committee. During the interview, the ICP confirmed the lack of real-time data. 2. On 10/31/11 at 3:04 PM RN #4, a surgical nurse, stated staff were instructed to clean the glucometer with alcohol wipes per the manufacturer's recommendation. On 11/2/11 at 11:20 AM an unidentified RN was observed demonstrating the use of alcohol wipes to clean the glucometer after patient use. Both that RN and the director of surgical services revealed the surgical and recovery nursing staff used alcohol to clean the glucometer per the manufacturer's recommendation. Review of the facility's policy and procedure entitled "Whole Blood Glucose Testing by Nursing Personnel," last revised June 2011, confirmed staff were to clean the glucometer with an alcohol wipe. Review of undated information from the CDC (provided by the facility) showed the following: "If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents." However, review of the CDC publication "Guideline for Disinfection and Sterilization in Healthcare Facilities", 2008, revealed the CDC does not recommend the use of alcohol to disinfect equipment when blood borne pathogens, such as hepatitis viruses, are a concern. The Association for Professionals in Infection Control & Epidemiology (APIC) recommendations for disinfecting point-of-care devices are published in the American Journal of Infection Control, April 2010. The APIC guideline recommends glucometers be disinfected with a dilute bleach solution or an Environmental Protection Agency (EPA)-registered disinfectant effective against hepatitis and human immunodeficiency viruses (HIV). Alcohol is not an EPA-registered disinfectant for blood borne pathogens. Both CDC and APIC further recommend that if a point-of-care device, such as a glucometer, cannot be effectively disinfected, then it should not be used to test multiple patients. 3. Observation in the medication room on the medical unit at 2:50 PM on 10/31/11 showed two clear glass mortars and pestles (devices for crushing/grinding medications) placed on a paper towel underneath the towel dispenser next to the handwashing sink. One mortar dish had been placed upside down and the other right side up; both were heavily covered with water spots. An additional observation on 11/3/11 at 8:30 AM revealed both devices remained in the same place. At that time the unit manager, RN #3, stated the devices were still used to crush medications and that they were washed after use. She verified the water spots on the devices and confirmed they should not be placed or stored under the towels where they could be contaminated.