Failure to Properly Disinfect Glucometer and Maintain Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper cleaning and disinfection of a blood glucose meter (BGM) after use with a resident who had complex medical conditions, including diabetes mellitus and dependence on renal dialysis. An LPN was observed using a single alcohol wipe to briskly clean only the front of the BGM before returning it to the medication cart, rather than following the facility's policy and the manufacturer's instructions, which require a two-step process using approved EPA-registered disinfectant wipes and a specified wet contact time. The LPN also demonstrated a lack of knowledge regarding the correct cleaning procedure, and the DON confirmed that the observed method was not compliant with facility policy or manufacturer guidelines. Additionally, the facility did not maintain enhanced barrier precautions (EBP) during medication administration through an enteral feeding tube for a resident with multiple medical devices and severe cognitive impairment. An LPN administered medication via the feeding tube without wearing a gown, despite the resident being on EBP per CDC guidelines and the facility's policy, which require the use of gowns and gloves during care involving enteral feeding tubes. The LPN acknowledged awareness of the EBP requirement but did not don the appropriate personal protective equipment during the procedure. Both deficiencies were confirmed through interviews with the involved LPNs and the DON, as well as review of facility policies and manufacturer instructions. The findings were based on direct observations, record reviews, and staff interviews, and affected multiple residents who either had their blood sugar checked with the BGM or had enteral feeding tubes requiring EBP.