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Based on document review and interview, the hospital failed to ensure a multi-use lancet pen used for a fingerstick to obtain blood and glucometer a device used to measure blood sugar levels was disinfected between patient use for 2 of 2 (P1 and P2) patients reviewed that required blood glucose monitoring.

Findings include:

P1's medical record was reviewed. The hospital's face sheet indicated P1 was admitted to the hospital on 6/25/2015.

Review of P1's Patient Order Form dated 6/25/2015 through 7/15/2015, indicated P1
was admitted to the hospital with diagnoses that included diabetes. P1's physician orders directed staff to obtain a fasting fingerstick blood glucose every morning. The order indicated P1 could use P1's personal glucometer and supplies.

P2's medical record was reviewed. The hospital's face sheet indicated P2 was admitted to the hospital on 5/19/2015.

Review of P2's Patient Order Form dated 5/19/2015 through 7/15/2015, revealed P2's diagnoses included diabetes. P2's physician orders directed staff to obtain a fingerstick blood glucose two times a day, before breakfast and before supper. Interview with the RN-A infection control nurse on 8/25/2015, at 10:45 a.m. revealed on 7/1/2015, she was made aware that P1's glucometer and lancet pen had been used for P2 on 6/29/2015 and 6/30/2015. RN-A said RN-C confirmed using P1's glucometer and lancet pen for P2. RN-A said the hospital provided glucometers for every patient that required blood sugar monitoring. When provided to the patient, the device was labeled with the patient's name on the glucometer, the storage bag, and a plastic container used to store the equipment. The glucometer and supplies were stored in the medication room. In addition, single use disposable lancets were used on the patients. On 7/1/2015, following the concern that P1's equipment had been used for P2, RN-A checked the storage container for P1's glucometer. The storage container was clearly marked with P1's name however, the glucometer and storage bag were not labeled. RN-A reviewed the blood sugar results and times stored in P1's glucometer and on 6/29/2015 and 6/30/2015, the glucometer had been used during the later afternoon. Following the possible blood exposure, P1 and P2 had blood drawn for hepatitis B, C and HIV. Both P1 and P2 tested negative for the infectious diseases and required follow-up blood work in 3 months.Interview with RN-C on 8/25/2015, at 2:47 p.m. confirmed she had used P1's glucometer and lancet pen for P2. RN-C said the storage container, glucometer, and multi-use lancet pen were not labeled for P1. RN-C indicated the evening of 6/29/2015 and 6/30/2015, she placed a new lancet in the multi-use pen, used the lancet pen to stick P2's finger for blood, and placed a drop of P2's blood on the test strip that was located in the glucometer. RN-C confirmed she did not clean the multi-use lancet pen or glucometer after testing P2's blood sugar. RN-C denied being trained to clean equipment that had been in contact with blood.

Interview with P1 on 8/28/2015, at 3:01 p.m. indicated on 6/30/2015, P1 noticed the supply of test strips were being used too quickly. P1 checked the memory on the glucometer and discovered blood glucose levels that were too elevated to be P1's results. P1 reported to the charge nurse that her glucometer and supplies had been used for P2. P1 said all of the supplies including the storage container, test strips, lancet, and glucometer were clearly labeled with P1's name.

Interview with the RN supervisor on 8/25/2015, at 3:30 p.m. revealed all licensed staff had received training on the hospital's policy and procedure for blood sugar monitoring and glucometer use. The training included cleaning the equipment after each use with a super sani-cloth germicidal disposable wipe and allowing two minutes of contact with the equipment. In addition, staff training included providing each patient with their own glucometer, a single use lancet, and test strips.

Review of the hospital's policy and procedure titled Blood Glucose Monitoring with an effective date of 3/23/2015, stated, only single use safety lancets would be used for finger sticks, not to use the same lancet on more than one patient, and disposing of the lancet at the point of use in a biohazard sharps container. Blood glucose monitors would be used for only one patient and not shared. The meters must be cleaned and disinfected after every use. All parts of the glucose monitors must be considered infectious and capable of transmitting blood borne pathogens. The disinfectant required had to be effective against the hepatitis B virus (HBV). The policy directed staff to follow the manufacturer's recommendation for disinfection of the blood glucose testing equipment.

The manufacturer's recommendation for disinfection of blood glucose monitoring equipment was the sani-cloth germicidal disposable wipes after every use. The germicidal solution required two minutes of contact time to kill HBV.