Failure to Disinfect Glucometer and Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to properly clean and disinfect an individually assigned glucometer according to the manufacturer's recommendations for a resident undergoing blood glucose monitoring. During observation, a nurse retrieved the resident's glucometer from a labeled plastic bag in the medication cart, used it to check the resident's blood glucose, and returned it to the bag without cleaning or disinfecting it before or after use. The nurse stated that glucometers were typically cleaned once a day unless visibly soiled, and that she did not perform the cleaning herself. Facility leadership and infection prevention staff confirmed that the policy required cleaning and disinfecting the glucometer with an EPA-registered disinfectant wipe before and after each use, regardless of individual assignment, and that the nurse had received recent training on this procedure. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for a resident with a chronic wound. During wound care observation, neither the wound care physician assistant nor the wound care nurse donned a gown while providing care for a sacral pressure ulcer, which included measuring, debriding, and dressing the wound. Interviews with the wound care nurse, physician assistant, and infection prevention staff revealed that the resident had previously been on EBP, but the sign indicating this had been removed, and there was uncertainty among staff about the current need for EBP. Facility policy required the use of gown and gloves for EBP during care of chronic wounds, and leadership confirmed that the resident's wound met criteria for EBP.