Failure to Disinfect Glucometers and Ensure Proper PPE Use for Residents on Contact Precautions
Penalty
Summary
The facility failed to ensure proper disinfection of glucometers between uses for residents requiring blood sugar monitoring. Specifically, a licensed practical nurse (LPN) was observed using an Accu-Check glucometer on a resident with diabetes and then cleaning the device with alcohol pads instead of the manufacturer-recommended bleach-based disinfectant wipes. Interviews with multiple staff members revealed inconsistent practices and understanding regarding the correct disinfection procedure, with some staff stating that alcohol wipes were used, while others mentioned bleach wipes or claimed each resident had their own glucometer. The facility's policy and the manufacturer's instructions both require the use of bleach-based disinfectant wipes for proper disinfection between residents, which was not consistently followed. Additionally, the facility failed to ensure that personal protective equipment (PPE) was properly used by staff when assisting a resident on contact precautions due to a diagnosis of shingles. A nursing assistant (NA) was observed entering the resident's room and donning a gown taken from a soiled laundry basket, rather than using a clean gown from the designated bin outside the room. The NA also entered the room on another occasion to retrieve meal trays without wearing any PPE or performing hand hygiene before or after the task. Interviews with staff confirmed that gowns in the laundry basket were soiled and should not be reused, and that staff were expected to wear gowns and gloves for all interactions with residents on contact precautions, including when entering the room to pick up trays. The residents involved had significant medical histories, including diabetes, Alzheimer's disease, and shingles, and required assistance with activities of daily living. The observed failures in infection prevention and control practices, including improper disinfection of shared medical equipment and inconsistent use of PPE, were not in accordance with facility policy or manufacturer guidelines. These deficiencies were identified through direct observation, staff interviews, and review of facility policies and procedures.