Failure to Follow Infection Control Procedures for Glucometer Disinfection, Hand Hygiene, and Linen Handling
Penalty
Summary
Nurse #1 failed to follow the manufacturer's instructions and facility policy for cleaning and disinfecting a shared blood glucose meter (glucometer) after checking a resident's blood glucose level. Instead of using an EPA-registered germicidal wipe as required, Nurse #1 used an alcohol wipe, which was not approved for this purpose. This practice was observed during a blood glucose check, and Nurse #1 stated she had always used alcohol wipes and was unaware of the need for an EPA-registered disinfectant. The shared glucometer was used for multiple residents on the unit, and the improper cleaning method was used between each resident. Additionally, the Wound Care Nurse did not adhere to the facility's hand hygiene policy during wound care for a resident. After cleansing a sacral wound, the nurse failed to change gloves and perform hand hygiene before applying a new dressing, instead using the same gloves to handle both the wound and the dressing materials. The nurse later acknowledged that hand hygiene and glove change should have occurred between these steps to prevent cross-contamination but did not perform them during the observed procedure. A separate incident involved a nurse aide who placed soiled linen, including towels and a gown, directly on the floor of a resident's room after providing a bath, rather than bagging the items as required by facility policy. The aide admitted to being aware of the correct procedure and having bags available but did not use them. The Director of Nursing confirmed that soiled linen should never be placed on the floor and should always be bagged immediately to prevent the spread of germs.
Removal Plan
- The Facility Consultant completed a medical record audit of all residents, including Resident #34, Resident #92, and Resident #97, who received blood glucose checks to identify any diagnosed blood-borne pathogen infections.
- The unit managers and the treatment nurse completed the cleaning and disinfecting of all resident glucometers in accordance with the manufacturer’s instructions.
- The Director of Nursing, Assistant Director of Nursing, Treatment Nurse and Unit Managers initiated, in person, education with all nurses and medication aides regarding the importance of following facility and manufacturer’s instructions for cleaning and disinfecting a shared glucometer.
- Any nurse or medication aide who has not worked or received the in-service will receive the education prior to the next scheduled work shift.
- All newly hired nurses or medication aides including agency, will be in-serviced by the Director of Nursing, Assistant Director of Nursing or Unit Managers during orientation regarding the importance of following facility and manufacturer’s instructions for cleaning and disinfecting a shared glucometer.
- The Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Managers initiated in-person return demonstrations of properly cleaning and disinfecting glucometers with all nurses and medication aides including agency.
- Any nurse or medication aide who does not successfully pass the return demonstration will be immediately re-educated and will be required to repeat the return demonstration until successful demonstration is achieved.
- Staff who have not completed the return demonstrations will complete it prior to their next scheduled work shift.
- The Director of Nursing, Assistant Director of Nursing and Unit Managers initiated in person quizzes with all nurses and medication aides, including agency to validate knowledge and understanding of the importance of following facility and manufacturer’s instructions for cleaning and disinfecting a shared glucometer.
- Any nurse or medication aide that does not successfully pass the quiz will be immediately re-educated and will be required to retake the quiz at the time of administration until a successful passing score is achieved.
- Any nurse or medication aide who has not completed the quiz will complete it prior to their next scheduled work shift.