| 62 |
BELLA TERRA OF BILLINGS |
275020 |
1807 24TH ST W |
BILLINGS |
MT |
59102 |
2016-12-15 |
441 |
E |
0 |
1 |
PSRD11 |
Based on observation, interview, and record review, the facility failed to utilize standard precautions to prevent the spread of infections by failing to disinfect a glucose monitor between uses to prevent indirect transmission for 2 (#s 12 and 22); and staff failed to wear gloves during a glucometer check for 1 (#22) of 22 sampled and supplemental residents. These deficient practices had the potential to affect all residents receiving glucometer monitoring and testing. Findings include: 1. During an observation on 12/12/16 at 4:40 p.m., staff member L checked resident #12's blood sugar with the Even Care glucometer. Staff member L returned to his medication cart and removed the used test strip and placed the strip in the sharps container. Staff member L placed the glucometer down on top of the medication cart. The staff member did not clean the glucometer with disinfecting wipes after checking resident #12's blood sugar. During an observation on 12/12/16 at 4:50 p.m., staff member L checked resident #22's blood sugar with the same, soiled, Even Care Glucometer, which was used to check resident #12's blood sugar. Staff member L returned to his medication cart after checking resident #22's blood sugar, removed the soiled test strip, and placed the test strip in the sharps container. Staff member L placed the glucometer on top of his medication cart. He did not disinfect the glucometer after checking resident #22's blood sugar. During an interview on 12/12/16 at 5:00 p.m., staff member L stated he was aware he needed to wash the glucometer between resident uses. The staff member stated he should use the disinfecting wipes with the purple top between each resident use. Staff member L stated he forgot due to being nervous. Staff member L stated he received his last training on the maintenance of the glucometers about one year ago. During an interview on 12/12/16 at 5:15 p.m., staff member D stated it was the expectation of all nurses and certified medication aides to wipe the glucometers with the purple top disinfecting wipes between each resident use. The staff member stated staff had training on the disinfection of the glucometers after the last annual survey. A review of the facility's policy and procedure titled, Blood Glucose Monitoring, showed, Disinfect glucometer after each use with 0.52% sodium hypochlorite solution or equivalent wipes and follow infection prevention guidelines to prevent carry-over of blood and infectious agents. A review of the facility's user's guide titled, Even Care G3, Professional Blood Glucose Monitoring System User's Guide, showed, Cleaning and Disinfecting Procedures for the Meter. The Even Care G3 Meter should be cleaned and disinfected between each patient. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. To disinfect your meter, clean the meter surface with approved disinfecting wipes. 2. During an observation on 12/12/16 at 5:03 p.m., Staff member L did not wash his hands or put on gloves before he approached resident #22. He cleaned the residents finger with an alcohol wipe. Waited for the resident's finger to dry, took the lancet and punctured the resident's finger. Staff member massaged the finger to bring a drop of blood to the surface of the finger. Staff member L applied the droplet of blood to the test strip which was docked in the glucometer. Staff member L did not wear gloves during the procedure. Staff member L did not disinfect his hands before or after the procedure. During an interview on 12/12/16 at 5:05 p.m., staff member L stated he was aware half way through the procedure that he was not wearing gloves. Staff member L stated he knew he should have washed his hands prior to donning gloves, and should not have checked the resident's blood sugar without wearing gloves. Staff member L stated the last training he had on hand hygiene was at the last monthly meeting. During an interview on 12/12/16 at 5:15 p.m., staff member D stated it was the expectation of staff to wear gloves when an encounter with known blood contamination may occur, such as, during blood glucose monitoring. Staff member D stated all facility staff were educated and trained monthly on hand hygiene. A review of the facility's policy and procedure titled, Blood Glucose Monitoring, showed, Wear proper PPE during blood glucose testing and administration of insulin. A review of the facility's user's guide titled, Even Care G3, Professional Blood Glucose Monitoring System User's Guide, showed, Step 1. Wash hands with soap and water. Step 2. Put on single-use medical protective gloves. |
2020-09-01 |