Failure to Properly Disinfect Shared Glucometer Between Residents
Penalty
Summary
Facility staff failed to follow the facility’s Glucometer Cleaning Policy and Procedure, dated 6/5/25, which requires disinfection of shared blood glucose monitoring equipment with a disinfecting wipe after each use and a 5-minute dry time. The deficiency involved two residents with physician orders for blood glucose monitoring three times daily (R8 and R103). On 8/25/2025 at 11:52 A.M., an LPN (V4) performed a finger-stick blood glucose test on R8 and then cleaned the shared glucometer with an alcohol pad instead of a disinfecting wipe, immediately placing the device in the top drawer of the medication cart without allowing the required disinfectant dry time. Seven minutes later, at 11:59 A.M., the same LPN used the same glucometer to perform a finger-stick blood glucose test on R103 and again cleaned the device only with an alcohol pad before returning it to the medication cart. On 8/27/2025 at 11:34 A.M., the DON (V2) confirmed that shared glucometers were required to be disinfected with a disinfecting wipe after each use, not an alcohol wipe. These observations, interviews, and record reviews showed that the facility did not implement its infection prevention and control program as written for disinfection of shared blood glucose monitoring equipment for two of two residents reviewed for blood glucose monitoring in a sample of 40.
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