F0880

E

Failure to Disinfect Glucometer and Adhere to Enhanced Barrier Precautions

San Angelo, Texas Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves failures in the facility’s infection prevention and control program related to glucometer disinfection and use of personal protective equipment (PPE) during care of a resident on Enhanced Barrier Precautions (EBP). During observation, an LVN obtained a fasting blood sugar from Resident #21 by taking a small blood sample from the resident’s finger and applying it to a test strip in a glucometer. After completing the blood sugar test, the LVN exited the room and placed the glucometer on the cart without sanitizing it. In interview, the LVN stated she used a tissue and hand sanitizer to sanitize the glucometer and reported she was unaware of what she was supposed to use to sanitize it. The DON stated that glucometers were supposed to be cleaned using bleach wipes, that nurses were trained upon hire and annually on proper disinfection of glucometers, and that the risk of not using the proper solution for sanitizing glucometers was passing on infections. Facility policy for glucometers required the meter to be cleaned with a germicidal and allowed to air dry between patient testings.

The deficiency also involves failure to follow EBP requirements for a resident with an indwelling urinary catheter. Resident #3 was admitted with neuromuscular dysfunction of the bladder and muscle weakness and had an indwelling catheter for neurogenic bladder. The resident’s care plan documented that she was on EBP, with an expectation that there would be no signs and symptoms of urinary infection and no transmission of infection from or to the resident. The care plan specified that gloves and gown should be donned for high-contact activities including linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity. The MDS assessment also indicated the presence of an indwelling catheter.

During observation, two CNAs entered Resident #3’s room to perform incontinent care. Both staff washed their hands and put on gloves but did not don gowns despite an EBP posting outside the room. They removed the resident’s brief, cleansed the vaginal area and urinary catheter tubing with wet wipes, turned the resident to her side, cleansed the rectal area where a bowel movement was present, repositioned the urinary catheter on the bed, and applied a new brief. In interviews, both CNAs acknowledged that the EBP posting indicated they were supposed to use PPE such as gloves and a gown when providing personal care for a resident with a urinary catheter, stated they had forgotten to wear a gown, and agreed they should have worn a gown along with gloves. The ADON stated staff were expected to wear EBP when providing care for residents with a urinary catheter and that the CNAs had been trained and were aware they had to wear PPE but had forgotten. The DON and Administrator both stated that failure to wear PPE as indicated could lead to infections or cross contamination. The facility’s Enhanced Barrier Precautions policy stated that EBP is indicated for residents with wounds and/or indwelling medical devices, including urinary catheters, and involves targeted gown and glove use during high-contact resident care activities.