Failure to Maintain Infection Control During Glucose Monitoring and Insulin Administration
Penalty
Summary
Staff failed to maintain proper infection control practices during blood glucose monitoring and insulin administration. A registered nurse used a blood glucose monitor on one resident, placing the device and used supplies into a plastic container without cleaning or disinfecting the monitor or the container afterward. The nurse also did not perform hand hygiene after removing gloves and before proceeding to care for another resident. The same glucose monitor and plastic container were used for another resident without cleaning or disinfecting between uses. The nurse also failed to perform hand hygiene before donning gloves and administering care to the second resident. Supplies, including the insulin pen and alcohol wipes, were placed back into the same uncleaned container after use. The infection preventionist confirmed that the facility's protocol required the glucose monitor to be cleaned with disinfecting wipes per manufacturer instructions, and that alcohol wipes were insufficient for disinfection. The infection preventionist also stated that hand hygiene should be performed before and after all resident care and that the plastic container should be cleaned after removing dirty supplies. Additionally, glucose testing and insulin administration were performed in the dining room, which was not in accordance with facility procedures. These actions and inactions were observed and confirmed through interviews and record review.