Failure to Properly Disinfect Blood Glucose Meter Between Residents
Penalty
Summary
The facility failed to implement proper infection control procedures regarding the use and disinfection of a multi-use blood glucose meter (BGM) for four residents who required fingerstick blood glucose testing. Facility policy and the manufacturer's instructions required that blood glucose meters intended for reuse be cleaned and disinfected between resident uses with an EPA-registered disinfectant detergent or germicide wipe. However, observations revealed that an LPN used only 70% isopropyl alcohol wipes to clean the blood glucose meter before and after each use, rather than the required EPA-registered germicidal wipes. The medication cart used by the LPN did not contain the appropriate disinfectant wipes as specified by the manufacturer and facility policy. Clinical record reviews showed that the affected residents had diagnoses including diabetes mellitus, viral hepatitis C, and human immunodeficiency virus (HIV), all of which can be transmitted via bodily fluids. Orders for these residents required frequent blood glucose monitoring and insulin administration based on sliding scale protocols. The LPN confirmed that the same blood glucose meter was used for multiple residents, and that only alcohol wipes were used for cleaning between uses, contrary to both policy and manufacturer instructions. Interviews with facility staff, including the DON and Infection Preventionist, confirmed that the expectation was to use EPA-registered germicidal wipes for disinfecting blood glucose meters. The failure to follow these procedures was observed directly by surveyors and acknowledged by staff, resulting in the determination of Immediate Jeopardy due to the increased likelihood of transmitting bloodborne pathogens between residents.
Removal Plan
- LPN 1 was removed from schedule immediately and will not be returning to the facility.
- Director of central supplies ensured that each of the eight medication carts had the disinfecting agents that meet the requirements of the Environmental Protection Agency (EPA) registered cleaning products as noted in the manufacturer's instructions.
- All nurses will be educated on the Obtaining a Fingerstick Glucose Level, policy and procedure. In addition, they will be educated on the necessity of using the approved EPA registered germicidal wipe as required in the manufacturer's instructions and where to obtain them. Education provided by the DON/designee. No licensed nurse will be permitted to begin their shift until they have been educated on the proper use and disinfection of the glucometer.
- Newly hired licensed nurses will be educated at orientation on the Obtaining a Fingerstick Glucose Level, policy and procedure using the approved EPA registered germicidal wipe requirements as noted in the manufacturer's instructions. All agency licensed nurses will be educated before they begin their first shift in the facility.
- Central supply department received education regarding ensuring that the EPA germicidal wipes are in the carts.
- DON/designee will complete random glucometer cleaning and disinfecting observation audits daily for seven days plus weekly for four weeks and monthly for three months ensuring education has been effective.
- DON/designee will be monitoring steps of the action plan for continued compliance.
- Central supply/designee will monitor ensuring the EPA germicidal wipes are in the carts.
- Audits will be brought to QA&A for review and recommendations.
- QAPI committee will determine the need for further audits.