**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of the facility's policies titled, Handwashing CC-INFC-28, Cleaning and Disinfecting Glucose Monitoring Systems INFC-73, the ASSURE BRILLIANCE COMPREHENSIVE SERVICE & SUPPORT PROGRAM, a facility document and www.merriam-webster.com, the facility failed to ensure Employee Identifier (EI) #1, a Registered Nurse and EI #8, a Licensed Practical Nurse (LPN) cleaned and disinfected a multi-use glucometer between resident use. During medication pass observation on 7/31/2019 beginning at 3:47 PM, EI #1, a RN failed to clean and disinfect the multi-use glucometer when she performed finger stick blood sugar monitoring for RI #37, RI #66, RI #69 and RI #98. EI #1 further failed to wash her hands prior to and after she removed gloves and place a barrier down on the residents' over-bed table, bed and/or furniture. During medication pass observation on 8/1/2019 beginning at 5:34 AM, EI #8, a LPN failed to disinfect the multi-use glucometer when she performed finger stick blood sugar monitoring for RI #2, RI #14 and RI #18. These deficient practices affected RI #2, RI #14, RI #18, RI #37, RI #66, RI #69 and RI #98, seven of 10 residents observed for finger stick blood sugar monitoring and placed these residents in immediate jeopardy for serious injury, harm, impairment or death. The facility has 33 residents who require finger stick blood sugar monitoring. On 8/4/2019 at 3:26 PM, the Administrator, Director of Nursing and the Nurse Quality Advisor were notified of the finding of immediate jeopardy in the area of Infection Control, F 880. Findings include: The facility's undated policy titled Handwashing CC-INFC-28 documented Purpose: To provide guidelines to employees for proper and appropriate handwashing techniques that will aid in the prevention of the transmission of infections. Policy: All employees shall adhere to handwashing procedure as outlined in this policy. Handwashing shall be regarded by the facility as the single most important means of preventing the spread of infections. Procedures: . When to Wash Hands . 7. After contact with blood, body fluids, secretions, excretions, mucous membranes, or broken skin; 8. After handling items or equipment potentially contaminated with a resident's blood, body fluids, excretions, or secretions; 9. After removing gloves; . The facility's policy titled Cleaning and Disinfecting Glucose Monitoring Systems INFC-73 revised September 2010, documented Purpose: To ensure that correct cleaning and disinfecting of the Glucose Monitoring System is followed to prevent the potential transmission of infectious organisms . Policy: The Glucose Monitoring System will be cleaned and disinfected between residents . Procedure: 1. The glucose monitoring system is cleaned/disinfected after each resident with Gluco-Chlor Disinfecting Wipes . The ASSURE BRILLIANCE COMPREHENSIVE SERVICE & SUPPORT PROGRAM revised April 2018, documented Cleaning and Disinfecting the Assure Prism multi Blood Glucose Monitoring System To minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfection procedure should be performed as recommended in the instructions below . The meter should be cleaned and disinfected after use on each patient . Guidelines for cleaning and disinfecting the Assure Prism multi: + Always were the appropriate protective gear, including disposable gloves. + Open disinfectant package. + Wipe the entire surface of the meter using the towelette at least 3 times vertically and 3 times horizontally to clean blood and other body fluids from meter. + Dispose of the towelette. + Allow the exterior to remain wet for 1 minute, then wipe meter dry using a dry cloth. + Use caution as to not allow moisture to enter the test strip port, data port or battery compartment, as it may damage the meter . CLEANING AND DISINFECTING FAQ (frequently asked questions) . What will happen if a blood glucose meter is not cleaned and disinfected after use? Per the CMS (Centers for Medicare and Medicaid Services) F(Federal) - Tag 880 guideline, surveyors may issue a citation if they observe no cleaning and disinfecting of meters after a blood glucose test as they would not be in compliance with CMS F-Tag 880 . Why is Cleaning and Disinfecting of blood glucose meters such a high priority? Blood glucose meters are at high risk of becoming contaminated with bloodborne pathogens such as Hepatitis B Virus (HBV), Hepatitis C (HCV) and Human Immunodeficiency Virus (HIV). Transmission of these viruses from resident to resident has been documented due to contaminated blood glucose devices. According to the Centers for Disease Control and Prevention, cleaning and disinfecting of meters between resident use can prevent the transmission of these viruses through indirect contact. How often do blood glucose meters need to be cleaned and disinfected? Per CMS F-Tag 880 Transmittal 55, blood glucose meters need to be cleaned and disinfected after each use for individual resident care . During medication pass observation on 7/31/2019 beginning at 3:47 PM, EI #1, a RN was observed to place the glucometer on the over-bed-table of RI #66, without a barrier. EI #1 did not wash or sanitize her hands before she put gloves on. After piercing the right middle finger of RI #66, to obtain a finger stick blood sugar, EI #1 did not clean and disinfect the glucometer. The glucometer used by EI #1 was an Assure Prism multi Blood Glucose Monitoring System. Without the cleaning or disinfecting the multi-use glucometer, at 4:00 PM, EI #1 proceeded to gather supplies to perform a finger stick blood sugar for RI #69. EI #1 laid the same glucometer used previously during RI #66's finger stick blood sugar, alcohol wipe and lancet on RI #69's bed. After pricking the left middle finger of RI #69 to obtain blood for the finger stick blood sugar, EI #1 placed the glucometer on the credenza in the resident's room without first placing a barrier. EI #1 discarded of the supplies and then laid the glucometer on top of the medication cart, without cleaning or disinfecting the multi-use glucometer. EI #1 removed her gloves but did not wash her hands. Without the cleaning or disinfecting the multi-use glucometer, at 4:05 PM, EI #1 proceeded to gather supplies to perform a finger stick blood sugar for RI #98. EI #1 used the same glucometer previously used during RI #66 and RI #69's finger stick blood sugar. EI #1 put gloves on without washing or sanitizing her hands. EI #1 placed the glucometer of RI #98's bed and over-bed-table, without first placing a barrier down. After EI #1 pricked the left middle finger of RI #98 to obtain blood for the finger stick blood sugar, EI #1 took her gloves off and did not wash or sanitize her hands. EI #1 placed the glucometer, without a barrier, on the medication cart without cleaning or disinfecting the multi-use glucometer. Without the cleaning or disinfecting the multi-use glucometer, at 4:08 PM, EI #1 proceeded to gather supplies to perform a finger stick blood sugar for RI #37. EI #1 placed the glucometer previously used during RI #66, RI #69 and RI #98's finger stick blood sugar, an alcohol wipe, gloves and a lancet on RI #37's over-bed-table, without placing a barrier down first. EI #1 did not wash her hands before she put gloves on or after she removed her gloves. After obtaining RI #37's blood sugar, EI #1 placed the glucometer on the medication cart without cleaning or disinfecting the multi-use glucometer. During an interview on 8/1/2019 at 11:57 AM, EI #1, RN was asked when she should wash her hands when wearing gloves. EI #1 answered, after the gloves are removed. When asked when she should wash her hands during a finger stick blood sugar, EI #1 replied, After you get done. EI #1 was asked did she wash her hands after removing her gloves when she obtained the finger stick blood sugar for RI #66. EI #1 replied, I can't really remember but I don't think so. EI #1 further acknowledged that she could not remember if she washed her hands after she removed her gloves during the finger stick blood sugar for RI #69, RI #98 and RI #37. When asked what she should do to clean and disinfect the glucometer, EI #1 stated, to take a Clorox wipe and wipe the glucometer off. EI #1 explained that she didn't use the Clorox wipe because there were none on her medication cart. EI #1 was asked if RI #66 was the first resident she performed a finger stick blood sugar for on 7/31/2019. EI #1 answered, she believed so. When asked if she cleaned and disinfected the multi-use glucometer after performing RI #66's finger stick blood sugar, EI #1 replied No ma'am. When asked if she cleaned and disinfected the multi-use glucometer after performing RI #69's finger stick blood sugar, EI #1 replied, No I didn't clean after any of them (residents). EI #1 acknowledged that she did not clean or disinfect the glucometer after obtaining RI #98's and RI #37's finger stick blood sugar. When asked what the concern was with not washing her hands after putting gloves on and taking them off, EI #1 said the spreading of germs. EI #1 was asked what the concern was with not cleaning and disinfecting the multi-use glucometer after each residents' finger stick blood sugar. EI #1 answered, Germs. When asked what she be placed down before putting a glucometer and other supplies on a resident's over-bed-table, bed and furniture, EI #1 said I have no idea, make sure area is clear. EI #1 was asked why she didn't clean and disinfect the multi-use glucometer between resident use. EI #1 stated she was nervous. EI #1 acknowledged she had been trained by the Staff Development Nurse, EI #5, on proper infection control procedures; however, she did not perform the procedures on 7/31/2019 as trained to do so. In an interview on 8/1/2019 at 3:12 PM, EI #3, the Director of Nursing (DON) stated she witnessed EI #1, a RN, perform finger stick blood sugars on 7/31/2019. EI #3 stated she witnessed EI #1 take the glucometer out of the drawer on the medication cart. According to EI #3, EI #1 did not clean (or disinfect) the glucometer before she performed the finger stick blood sugars. EI #3 stated she noticed EI #1 did not have gloves or a barrier in her hand, so she (EI #3) assumed the observation would not go well. When asked what the potential for harm was in not cleaning and disinfecting the glucometer, EI #3 replied, infection. In a follow-up telephone interview on 8/2/2019 at 10:57 AM, EI #1, a RN was asked how she was taught to clean and disinfect the glucometer, EI #1 replied, before using the glucometer, wipe it down then lay it on a barrier, clean the resident's finger then prick it to check the blood sugar; inform the resident what his/her blood sugar is; then wash your hands and rub down the glucometer. EI #1 was asked to explain what she meant by rub down the glucometer. EI #1 stated, the front, the buttons and the back and make sure the glucometer is dry before performing another finger stick blood sugar. During medication pass observation on 8/1/2019 at 5:34 AM, EI #8, a Licensed Practical Nurse was observed to perform a finger stick blood sugar for RI #18. EI #8 pricked the right middle finger of RI #18 and afterwards discarded of the lancet and test strip in the sharps container. EI #8 used a germicidal ([NAME]) wipe and cleaned the glucometer, then wrapped the glucometer in a paper towel. At 5:50 AM, EI #8 unwrapped the previously glucometer from the paper towel and gather her supplies to perform a finger stick blood sugar for RI #2. After obtaining the resident's blood sugar, EI #8 cleaned the glucometer with a wipe and wrapped it in a paper towel. At 6:26 AM, after obtaining RI #14's finger stick blood sugar, EI #8 cleaned the glucometer with a germicidal wipe then wrapped the glucometer in a paper towel to dry. In an interview on 8/2/2019 at 12:39 PM, EI #8, a LPN was asked how she was trained to clean and disinfect the glucometer. EI #8 replied, after putting on gloves, to place the glucometer on a paper towel, then get a [NAME] disposable wipe and wipe the front of the glucometer. After the glucometer was cleaned, place the glucometer on a paper towel for at least 5 minutes to let it air dry. On 8/1/2019 at 3:45 PM, an interview was conducted with EI #4, the Assistant Director of Nursing/Infection Control Nurse. EI #4 was asked what should be done before and after removing gloves prior to and following a finger stick blood sugar. EI #4 replied, wash your hands. When asked what should be placed before laying a glucometer and other supplies on a resident's over-bed-table, bed and/or other furniture, EI #4 answered A barrier, paper towel, plastic tray with paper towel underneath. EI #4 was asked, when should the glucometer be cleaned and disinfected and she stated, before and after resident use. When asked to explain the steps as to how staff should clean and disinfect the glucometer, EI #4 replied, put on gloves and use an antibacterial wipe to clean the glucometer then place the glucometer on a tray for five minutes. After the finger stick has been obtained, the nurse should remove her gloves, wash her hands, dispose of the lancet and wipe down the glucometer with an antibacterial wipe and place it in a paper towel and let it dry for five minutes. EI #4 was asked what the glucometer should be cleaned and disinfected with. EI #4 replied, Antibacterial germicidal wipes. When asked what the potential for harm was in not cleaning and disinfecting the glucometer after each use, EI #4 answered The potential for transmitting germs from one resident to another. Blood borne pathogens. In an interview on 8/3/2019 at 10:57 AM, EI #5, the Staff Development Coordinator was asked, what was the concern of not following the manufacturer's recommendations for the cleaning and disinfecting of the glucometer. EI #5 answered, the concern was the glucometer could not be cleaned and disinfected properly and there could possibly be a spread of infections. During a follow-up interview with EI #3, the DON on 8/3/2019 at 3:36 PM, she was asked, what was the concern of not following the manufacturer's recommendations for the cleaning and disinfecting of the glucometer. EI #3 replied, spread of blood borne pathogens and damage to the equipment. When asked if the disinfectant wipe was effective if it was not being used according to the manufacturer's recommendations, EI #3 said possibly no. In a document provided by the facility dated 8/2/2019, the facility has a total of 48 residents diagnosed as having Diabetes. Of the 48 residents diagnosed with Diabetes, 33 residents required finger stick blood sugar monitoring. The document further indicated there were residents residing in the facility with a communicable disease, one of which required finger stick blood sugar monitoring. A communicable disease, as defined by www.merriam-webster.com, is an infectious disease transmissible by direct contact with an affected individual or the individual's discharges or by indirect means. ************************* On 8/4/2019 at 9:16 PM, the facility submitted an acceptable Removal Plan, which documented Generations of [NAME] Removal Plan F 880 Infection Control 1. The registered nurse who failed to clean and disinfect the Assure Prism multi-use glucometer according to the manufacturer's recommendations between each resident when performing finger stick blood sugars on RI #66, RI #69, RI #98 and RI #37 was suspended on 7/31/19 pending a facility investigation and will not return to work until she goes through a thorough orientation re-training on cleaning and disinfecting the Assure Prism multi-use glucometer according to manufacturer's recommendations between each resident when performing finger stick blood sugars. 2. All Assure Prism multi-use glucometers were properly cleaned and disinfected per manufacturer's recommendations on 8/3/19 by licensed nurses after they received re-training on cleaning and disinfecting the Assure Prism multi-use glucometer by the Nurse Consultant using a manufacturer's approved recommendation germicidal wipe, PDI Super Sani-Cloth. 3. Licensed staff present on 8/2-8/3/19 were re-trained on cleaning and disinfecting the Assure Prism multi-use glucometers by the Nurse Consultant and Clinical Coordinator by lecture, return demonstration and verbalization of understanding of the process to clean and disinfect the Assure Prism multi-use glucometer at the following times: 8/2/19 9:13 p - 10:00 p 8/3/19 8:15 a.m. - 10:13 a.m. 8/3/19 10:20 a.m. - 10:35 a.m. 8/3/19 6:45 p.m. - 7:15 p.m. There are 33 residents who receive finger stick blood sugar monitoring and one of those 1 resident has a communicable disease. Date of alleged immediacy removed on 8/4/19. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F 880 was lowered to a D level on 8/4/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.