Failure to Implement Effective Infection Control for Glucometer Use and PPE Compliance
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observations of improper cleaning and disinfection of shared glucometers used for blood glucose monitoring. Staff, including RNs and LPNs, did not follow the manufacturer's instructions for cleaning and disinfecting the glucometers, such as using the correct EPA-approved wipes, performing the required cleaning and disinfection steps, and ensuring the proper dwell time for disinfectant. In several instances, staff used unapproved wipes, did not allow the disinfectant to remain wet for the required time, and failed to use two wipes as instructed. Additionally, glucometers were stored improperly, often in direct contact with each other and without barriers, increasing the risk of cross-contamination. One resident with a bloodborne illness (HIV) was among those receiving fingerstick glucose checks with shared devices. Further deficiencies were observed in the use of Enhanced Barrier Precautions (EBP) and personal protective equipment (PPE) during high-contact care activities. Staff members, including CNAs and nurses, were seen providing direct care to residents on EBP without donning appropriate PPE such as gowns and gloves, despite clear signage and facility policy requirements. In several cases, staff failed to perform hand hygiene before and after glove use, and in some instances, left resident rooms and handled equipment or supplies with contaminated gloves. These lapses occurred with residents who had wounds, indwelling catheters, or multidrug-resistant organism (MDRO) infections, all of whom required strict adherence to infection control protocols. Additionally, the facility did not ensure proper cleaning of non-critical resident care equipment, such as Hoyer lifts. Observations revealed visible contamination on the base of a mechanical lift, and staff interviews confirmed that cleaning after each use was expected but not consistently performed. These failures in infection control practices were identified through direct observation, staff interviews, and review of facility policies and CDC guidelines, and had the potential to affect all residents receiving fingerstick blood glucose checks and those requiring high-contact care.