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Based on the review of hospital policy and procedures, manufacturer recommendations, observations, and staff interviews, the nursing staff failed to clean a glucometer after patient testing in 3 of 3 patient observations of glucometer use (#12, #13, and #10).

Findings include:

Review of the facility policy and procedure revealed there is no policy that addressed cleaning the McKesson True Metrix Pro Profession Monitoring Blood Glucose Meter currently being used in the facility.

Review of the "McKesson True Metrix Pro Professional Monitoring Blood Glucose Meter Owner's Manual" with a revision date of 01/2018 revealed "...Meter should be cleaned and disinfected between paitents ... To Clean and Disinfect the Meter ... 2. To Clean: Make sure meter is off and test strip is not inserted. With ONLY (Company Name) Super Sani Cloth Wipes ..., rub the entire outside of the meter using 3 circular wiping motions with moderate pressure on the front, back, left side, right side, top and bottom of the meter ..."

1. Medical record review on 12/11/2019 revealed Patient #12, a 63-year-old male was admitted on 12/05/2019 with a diagnosis of Substance Abuse, and Depression with a history of Diabetes. Review of the physician orders by MD #1 dated 12/06/2019 revealed glucometer-finger stick blood sugar testing to be done before meals and at bedtime 4 times a day.

Observation on 12/11/2019 at 1122 on an adult unit revealed the RN #1 (Registered Nurse) performed a finger stick blood sugar on Patient #12 using the McKesson True Metrix Pro Professional Monitoring Blood Glucose Meter. RN #1 set the glucometer down on the medication cart, discarded the trash, then removed her gloves and performed hand hygiene. Observation revealed the RN did not clean the glucometer before she began a finger stick glucose test on the next patient (Patient #13).

Interview on 12/12/2019 at 1420 with the Nurse Educator revealed the expectation was for the glucometer to be cleaned after each Patient use and prior to being placed back in the zipper storage pouch.

Interview on 12/12/2019 at 0925 with the DON (Director of Nursing) revealed the expectation was for the glucometer to be cleaned after each Patient use.

2. Medical record review on 12/11/2019 revealed Patient #13, a 53-year-old male was admitted on 12/09/2019 with a diagnosis of ETOH Abuse, (Alcohol Abuse) Depression with a history of Diabetes. Review of the physician orders by MD #1 dated 12/09/2019 revealed glucometer-finger stick blood sugar testing to be performed before meals and at bedtime, 4 times each day.

Observation on 12/11/2019 at 1128 on an adult unit revealed RN #1 (Registered Nurse) performed a finger stick blood sugar on Patient #13 using the McKesson True Metrix Pro Professional Monitoring Blood Glucose Meter. The RN #1 set the glucometer down on the medication cart, discarded the trash, then removed her gloves and performed hand hygiene. Observation revealed that RN #1 did not clean the glucometer between patients. (Patient #12 and Patient #13).

Interview on 12/12/2019 at 1420 with the Nurse Educator revealed the expectation was for the glucometer to be cleaned after each Patient use.

Interview on 12/12/2019 at 0925 with the DON (Director of Nursing) revealed the expectation is for the glucometer to be cleaned after each Patient use.







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3. Observation on 12/11/2019 at 1145 on an adult unit revealed RN (Registered Nurse) #2 performed a finger stick blood sugar on Patient #10 using the McKesson True Metrix Pro Professional Monitoring Blood Glucose Meter. RN #2 placed the lancet and glucose testing strip in the red sharps container then placed the glucometer back in the zipper pouch. The RN zipped the pouch closed, discarded the trash, then removed her gloves and performed hand hygiene. Observation revealed the RN did not clean the glucometer prior to putting it back in the zipper storage pouch. Observation revealed after this surveyor asked about the cleaning of the glucometer, the RN removed the glucometer and wiped it with an alcohol pad.

Interview on 12/11/2019 at 1150 with RN (Registered Nurse) #2 revealed the nurse was trained to use an alcohol pad to clean the glucometer.

Interview on 12/ 12/2019 at 1445 with the Nurse Educator revealed the expectation is for the glucometer to be cleaned after each patient and prior to being placed back in the zipper storage pouch. Interview revealed the glucometer should not have been cleaned with an alcohol pad.


NC00154963, NC00158938