Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 531310	(X3) Date Survey Completed 05/03/2012
Name of Provider or Supplier Powell Valley Hospital	Street Address, City, State 777 Avenue H, Powell, 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)

C0278

PATIENT CARE POLICIES
CFR(s): 485.635(a)(3)(vi)

[The policies include the following:] 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 policies and procedures, the manufacturer's instructions, and information from the CDC, the facilty failed to ensure standards of practice were maintained related to infection control practices. This failure involved cleaning and disinfecting all glucometers and lack of proper disinfection of equipment in the clinic, emergency department, and rehabilitation/therapy department. In addition, monitoring of hand hygiene practices in all departments of the facility was not part of the surveillance program. The findings were: 1. According to the facility's policies and procedures "Waived Laboratory Testing" Policy:A.101, last reviewed/revised 5/11, staff were to follow the user manual for the "Accu-chek Blood Glucose Monitoring System." On 5/2/12 during interview at 2:30 PM, the laboratory director confirmed staff followed manufacturer's instructions for cleaning and disinfecting glucometers. Review of those instructions ("Accu-Chek Advantage Owner's Booklet") showed appropriate cleaning solutions were "70% alcohol, Mild dishwashing liquid mixed with water, 10% household bleach solution (1 part bleach in 9 parts water) made the same day." At 9 AM on 5/3/12 the laboratory director stated she had checked and staff used an alcohol pad to clean glucometers. She presented the surveyor with an individual package labeled "Alcohol Prep Pad" and the contents were described as "70% Isopropyl Alcohol." The surveyor called the manufacturer, Roche, on 5/3/12 at 1:30 PM and was informed that they would fax new information on cleaning and disinfecting Accu-Chek glucometers that met the CDC guidelines. Review of that information, dated 10/19/10, showed the CDC had revised their guidelines for "proper cleaning and disinfecting of blood glucose meters" and "this may require changes in your facility policies." Reference: The CDC publication "Guideline for Disinfection and Sterilization in Healthcare Facilities", 2008, 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. Alcohol is not an EPA-registered disinfectant for blood borne pathogens. Both CDC and APIC further recommended 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. 2. Observation on 5/1/12 during a tour of the clinic at 2:15 PM showed staff used "SaniCloth Plus" wipes for disinfecting tables (patient beds) and chairs. Interview with RN #6 at that time revealed she allowed the surface to air dry for "approximately one minute" but had never timed the actual wet contact time of the disinfectant. Further, she was unaware a wet contact time was required. Cleaning of equipment in the emergency department showed "SaniCloth Plus" wipes were used. The ambulance staff used "Virex Tb" to clean their gurney. The unidentified ambulance member cleaning the gurney stated she was unaware of the required wet contact time. Interview with the rehabilitation director and tour of the department on 5/2/12 at 3:38 PM showed "Virex Tb" was used to disinfect the equipment between patients. The director stated staff did wait, but he was not sure there was always a three minute wet contact time. References: Review of the manufacturer's instructions printed on the label of the container of "SaniCloth Plus" showed: "To disinfect nonfood contact surfaces only: Use a wipe to remove heavy soil. Unfold a clean wipe and thoroughly wet surface. Treated surface must remain visibly wet for a full three (3) minutes. Use additional wipes if needed to assure continuous three (3) minute wet contact time. Let air dry." Review of the label instructions for "Virex Tb" showed a three minute wet contact time was required for disinfecting equipment. 3. During an interview on 5/1/12 at 3:30 PM, the infection control practitioner (ICP) stated hand hygiene was discussed in orientation but was not monitored. He further stated demonstrations of hand hygiene would be added to the yearly competency/education fair, but he acknowledged that he did not currently monitor opportunities for hand hygiene among staff nor the overall compliance rate for hand hygiene at the facility.