Failure to Follow Infection Control Protocols for Glucometer Disinfection, Catheter Care, and Catheter Bag Positioning
Penalty
Summary
Staff failed to follow infection prevention and control standards in several instances involving multiple residents. During blood glucose monitoring, a registered nurse did not disinfect a multi-use glucometer with an approved EPA disinfectant between residents, instead placing the device back into the caddy without cleaning. On another occasion, the same nurse used the glucometer on a second resident without prior disinfection. When the glucometer was eventually cleaned, the nurse did not allow it to dry before storing it. Other staff members were observed using alcohol wipes, which are not approved by the manufacturer, instead of the required germicidal wipes. The facility's policy and the manufacturer's guidelines both require the use of germicidal wipes and adherence to specified drying times between uses on different residents. In another incident, a certified nursing assistant provided catheter care to a resident on Enhanced Barrier Precautions (EBP) without wearing the required personal protective equipment (PPE), including gown and gloves. The assistant also failed to use soap during catheter care, did not change gloves when moving from a dirty to a clean area, and did not perform appropriate hand hygiene. The assistant admitted to not following the correct procedures, and both a registered nurse and the director of nursing confirmed that the expected protocol was not followed for residents on EBP. Additionally, staff failed to maintain proper positioning of a urinary catheter bag for a resident, with the bag observed resting on the floor on multiple occasions. Facility policy requires that catheter bags be kept below the level of the bladder and off the floor to prevent infection. Interviews with nursing staff confirmed that the observed positioning did not meet infection control standards.
Removal Plan
- Residents who require blood sugar monitoring will have their glucometers cleaned after each use with the appropriate disinfectant that will kill bloodborne pathogens and kept out until the dry time has completed.
- Two glucometers will be placed in each nurses cart to allow for time in-between use to allow for proper disinfection.
- The Interdisciplinary Team will be educated by the Regional Director of Clinical Services on the facility policy for using glucometers to maintain infection control standards. This education will cover how to disinfect the glucometer after use on each patient and the required dry time to prevent the spread of bloodborne infections.
- All licensed nursing staff will be educated by the DON or designee on the glucometer cleaning policy per manufacturer guidelines to include the steps to take to use and disinfect after each patient.
- This education will be provided to agency nurses prior to starting with the facility.
- Any nurse who hasn't completed will be educated before the start of their next shift.
- The Administrator to conduct an ADHOC Quality Assurance Performance Improvement Meeting including the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Director of Social Work, Activities Director, Dietary Manager, Business Office Manager, Director of Housekeeping and Laundry, and Unit Managers to review the policy for the use of glucometers.
- DON or designee will monitor the procedure for disinfecting the glucometer between residents by random observations of glucometer usage/use five times per week for four weeks and weekly for four weeks.
- The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone.