Failure to Disinfect and Appropriately Assign Glucometer During Blood Glucose Monitoring
Penalty
Summary
Facility staff failed to follow infection prevention and control protocols during blood glucose monitoring for a resident with diabetes. Specifically, a nurse was unable to locate the assigned glucometer for a resident and instead used a glucometer labeled for another resident without cleaning or disinfecting it before or after use. The nurse did not follow the facility's policy or the manufacturer's instructions for cleaning and disinfecting the glucometer, which required the use of two germicidal wipes—one for cleaning and one for disinfecting, with a two-minute wet contact time. The incident was observed during a medication administration, where the nurse retrieved a glucometer from the medication cart, which was stored in a plastic bag labeled for a different resident. The nurse proceeded to check the blood glucose level of the intended resident using this device, then placed the glucometer and its storage bag on a table in the resident's room. Upon questioning, the nurse stated she believed the glucometer was new and unused, but a review of its history showed several previous blood glucose readings had been recorded. The nurse acknowledged she should have obtained a replacement glucometer from the facility's supply room but did not do so due to feeling anxious during the observation. Interviews with facility leadership confirmed that each resident was supposed to have a personal, labeled glucometer, and that staff were expected to follow strict cleaning and disinfection protocols after each use, regardless of whether the glucometer was intended for single or multiple residents. The nurse involved was aware of the correct procedures but failed to implement them during the incident. The facility's policy and the manufacturer's instructions for both the glucometer and disinfectant wipes were not followed, resulting in a breach of infection control standards.
Removal Plan
- Identify all residents who require blood glucose monitoring with a glucometer as potentially affected.
- Interview current nurses and medication aides to confirm no other instances of improper glucometer use.
- Interview alert and oriented residents to confirm no observed improper glucometer use.
- In-service Nurse #1 on manufacturer’s recommendations for disinfectant wipes and glucometer cleaning/disinfection, including observed return demonstration.
- Educate Nurse #1 on potential consequences of improper glucometer cleaning/disinfection.
- Remove and discard Resident #141’s glucometer; provide new, labeled glucometers for Resident #11 and Resident #141.
- Notify Resident #11 of the incident and offer bloodborne pathogen screening.
- Notify Medical Director and discuss education and system changes to prevent recurrence.
- Provide education to all nurses and medication aides on manufacturer’s recommendations for disinfectant wipes and glucometer cleaning/disinfection, and system for keeping glucometers in resident rooms labeled.
- Audit all residents requiring glucometers to ensure each has a labeled glucometer in their room.
- Provide education to staff not present via telephone and require return demonstration before next shift.
- Include glucometer cleaning/disinfection education in orientation for new nurses and medication aides.
- Direct staff to retrieve a new glucometer from Central Supply if a resident’s glucometer cannot be located, label it, and notify Unit Manager.
- Assess, clean, and disinfect all glucometers according to manufacturer recommendations.
- Conduct audit to verify all residents requiring glucose monitoring have individualized, labeled glucometers available.
- Place glucometer policy on every medication cart.
- Move glucometers from medication carts to resident rooms, stored in labeled containers.
- Educate staff on new glucometer storage locations and policy.
- Institute disciplinary action for any staff found sharing glucometers.
- Notify County Department of Health of the incident.