Failure to Properly Disinfect Shared Blood Glucose Meters
Penalty
Summary
Facility staff failed to properly clean and disinfect shared blood glucose meters before and after each use, as required by both facility policy and the manufacturer's instructions. Observations revealed that staff used alcohol wipes instead of EPA-registered disinfectant wipes, and in some cases, did not disinfect the meters at all prior to use. This practice was observed during blood glucose checks for two residents, both of whom were identified as having bloodborne pathogens, including hepatitis C. The blood glucose meters were not labeled for individual resident use and were stored in a manner that allowed for potential cross-contamination. Nursing staff, including a nurse and the Assistant Director of Nursing (ADON), demonstrated a lack of knowledge regarding the correct disinfection procedures. The nurse stated he was trained to use alcohol for cleaning, and the ADON admitted she was unaware that the meter needed to be cleaned both before and after each use. Both staff members had previously received training on blood glucose meter disinfection, but failed to follow the correct procedures during observed care. The facility's policy and the manufacturer's guidelines both specified the use of EPA-registered disinfectant wipes with a required contact time, which was not followed. The deficiency was identified during direct observation and interviews, which confirmed that the improper cleaning and disinfection of blood glucose meters occurred while caring for residents with known bloodborne pathogens. The facility's monitoring systems failed to detect or correct these lapses in infection control, and staff continued to use shared meters without proper disinfection, increasing the risk of cross-contamination and exposure to bloodborne infections among residents.
Removal Plan
- Removed and discarded prior blood glucose meters that were being utilized for multi-resident use.
- Placed individual blood glucose meters in a zipped plastic bag with resident's name identifier to prevent cross contamination.
- Blood glucose meters are removed from the zipped plastic bag prior to entering the resident room, then cleaned, disinfected, and air-dried per EPA-registered disinfectant wipe manufacturer's recommendation before and after use.
- Blood glucose meters are stored in each resident's respective medication cart.
- Applied residents' names to the individual blood glucose meters.
- Upon resident discharge, blood glucose meter is disinfected with EPA-registered disinfectant wipe and stored in medication room.
- All new admissions and residents with new blood glucose meter testing orders will be given a new blood glucose meter by the nurse receiving the order and/or admitting nurse.
- Nurse and/or admitting nurse will label the blood glucose meter and baggy with resident's name and place it in their respective medication cart.
- Education provided to all Licensed Nurses on the specific resident use of blood glucose meters, storage, cleaning, and disinfecting using proper EPA-disinfecting wipe.
- Licensed Nurses who have not received the education will be removed from the schedule until the education has been completed.
- Education related to cleaning, disinfecting, and storage of individual blood glucose meters will be added to the general orientation of newly hired Licensed Nurses.
- Administrator and/or Director of Health Services is responsible for ensuring all Licensed Nurses are educated.
- Licensed nurses who are scheduled to work will receive in-person education and complete return demonstration of cleaning and disinfecting blood glucose meters.
- Licensed Nurses who are not scheduled to work will receive over the phone education with return demonstration review by Director of Health Services prior to next scheduled shift.
- Administrator and/or Director of Health Services maintains the employee roster of those who have been educated and who require review.
- Facility contacted the local health department regarding the infection control breach.
- Medical Director was notified of the infection control breach.