Failure to Use and Disinfect Resident-Assigned Glucometer
Penalty
Summary
Facility staff failed to utilize a resident's assigned, labeled blood glucose meter (glucometer) and instead used a loose, unassigned, and unlabeled glucometer from the medication cart to check a resident's blood glucose level. The staff member did not disinfect the glucometer before or after use and had no way to verify if it had previously been disinfected. This occurred despite the facility having a policy that required cleaning and disinfecting glucometers between resident use, following manufacturer instructions and infection control standards. At the time of the incident, there were 11 residents in the facility with known bloodborne pathogens, and 4 of these residents required blood glucose monitoring. The observation revealed that the nurse used the loose, unlabeled glucometer on a resident, even though the resident had a designated, labeled glucometer stored in the medication cart. The nurse admitted to not knowing why she did not use the assigned glucometer and confirmed she did not disinfect the device before or after use. The nurse also stated she was unsure if the glucometer had been disinfected previously and placed it back in the cart without cleaning it. Further interviews and observations indicated that the presence of a loose, unlabeled glucometer in the medication cart was not an isolated incident, as another nurse confirmed the existence of such a device, which was reportedly for emergencies but had no clear disinfection protocol. The facility's infection preventionist and DON acknowledged previous issues with glucometer disinfection and had implemented measures such as audits, education, and visual cues, but these were not consistently maintained. The incident was observed and confirmed by multiple staff, and the facility's leadership was unaware that visual cue cards were missing and that a loose glucometer was still present on the cart.
Removal Plan
- Reviewed and updated the facility's Glucometer Procedure: Use, Cleaning, and Infection Control policy to reflect corrective actions and emphasize use of individually assigned, labeled glucometers.
- All licensed nursing personnel acknowledged receipt and understanding of the updated glucometer policy.
- Conducted a comprehensive, system-wide audit to ensure every resident requiring blood glucose monitoring had an individually assigned, correctly labeled glucometer stored in a designated container.
- Removed and discarded all unauthorized/unlabeled glucometers from circulation.
- Implemented a strict protocol for the introduction of new or replacement glucometers, requiring all new glucometers to be delivered to and distributed from the DON's office, labeled for a specific resident before use.
- Prohibited storage of unassigned or unlabeled stock glucometers on medication carts or in general nursing units outside of DON office control.
- Established a process for after-hours or weekend glucometer assignment, requiring nursing leadership to obtain and assign glucometers from the DON's office.
- Updated protocol for removal and discarding of unused glucometers for discharged residents during routine audits.
- In-serviced the Central Supply Clerk and nursing leadership on the new glucometer control protocol.
- Reviewed and confirmed placement of laminated visual reminders outlining glucometer use and disinfection steps on all medication carts and in medication rooms.
- Updated equipment management protocol to require DON or nursing leadership to verify and reinstall all necessary signage and visual aids after any medication cart modification, replacement, or repair.
- Conducted immediate in-service training for all licensed nursing staff (including agency nurses) on the updated Glucometer Procedure: Use, Cleaning, and Infection Control policy.
- Emphasized in training the use of individually assigned glucometers, proper storage, and strict prohibition of using unlabeled or shared glucometers.
- Reinforced hand hygiene procedures and correct use of supplies during blood glucose monitoring.
- Detailed and trained staff on the two-wipe method for cleaning and disinfecting glucometers, including required contact time and air drying.
- Educated staff on the updated procedure for obtaining a new, properly labeled glucometer if a resident does not have one.
- Required all staff to sign an acknowledgement form confirming receipt and understanding of the training.
- Completed direct observational competency validation for all licensed nursing staff (including agency nurses) on blood glucose monitoring procedures.
- Incorporated comprehensive education and competency validation into orientation for all new nursing hires and agency staff, with annual competency refreshers.
- Assigned DON, ADON, and scheduler responsibility for maintaining records of all completed training, signed acknowledgement forms, and competency validations.
- Implemented ongoing direct supervisory support and surveillance of licensed nurses, including agency nurses, to ensure continued adherence to correct blood glucose monitoring procedures.
- Terminated the employment of the agency nurse involved in the incident.
- Notified the medical provider and responsible party for Resident #8 of the incident.
- Removed and discarded the unlabeled glucometer used in the incident.
- Completed an immediate inventory check to confirm sufficient individually assigned, labeled glucometers and appropriate EPA-registered disinfectant wipes were available.
- Reported the infection control breach to the local health department and followed their recommendations, including baseline testing for HIV, Hepatitis B, and Hepatitis C for Resident #8.
- Conducted a root cause analysis to identify contributing factors and inform corrective actions.