Based on observations, record review, and staff, Nurse Practitioner, and Medical Director interviews, the facility staff failed to follow the manufacturer's instructions for cleaning and disinfecting of a shared glucometer between resident usage for 2 of 2 residents whose blood sugar levels were checked (Resident #58, Resident #1). Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-approved disinfectant in accordance with the manufacturer's instructions for disinfection of the glucometer potentially exposes residents to the spread of blood borne infections. There were two residents with a bloodborne pathogen in the facility at the time of the investigation. Immediate Jeopardy began on 03/12/25 when Nurse Aide #1 was observed performing blood glucose checks on residents using a shared glucometer without disinfecting per manufacturer's instructions. Immediate jeopardy was removed on 03/14/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring systems are in place. Findings included: The undated glucometer manufacturer's instructions for cleaning and disinfecting indicated that the blood glucose monitoring system may only be used for testing multiple patients when standard precautions and the manufacturer's disinfecting procedures are followed. The meter should be cleaned and disinfected after use on each patient. Additional instructions were to use a purple top wipe or an orange top bleach wipe if the resident was on enteric precautions. Review of the facility policy Glucometer Disinfection revised in September 2021 read, in part, to clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. The procedure for disinfecting glucometers included: The manufacturer's guidelines are as follows: put on clean gloves, clean the glucometer as below with Germicidal Disposable Wipes ([purple top] for all non-contact enteric isolation) or Bleach Germicidal Wipes ([orange wipes] if resident on contact enteric isolation) - Place the meter on a level surface and ensure meter has been powered off - Obtain appropriate wipe and squeeze excess liquid from wipe - Wipe the meter to clean by gently wiping the outside of the meter and carefully wipe around the test strip port area, making sure that no liquid enters the test strip port - Dry the meter thoroughly with a dry cloth or gauze. Visually verify that no solution is seen anywhere on the meter at the completion of cleaning - Use a fresh wipe to disinfect by gently wiping the outside of the meter three times horizontally and three times vertically and carefully wipe around the test strip port area, making sure that no liquid enters the test strip port. - Allow the surface of the meter to remain damp with the recommended contact time (two minutes for purple-top, 4 minutes for orange-top) - Dry the meter thoroughly with a dry cloth or gauze. Visually verify that no solution is seen anywhere on the meter at the completion of cleaning and disinfecting. - If further testing is not needed, return the meter to the base unit to charge the battery. The purple top wipes container which was located at the nurse's station read in part to disinfect nonfood contact surfaces to thoroughly wet surface, allow treated surface to remain wet for two minutes and let air dry. These wipes were an EPA-registered germicidal wipe and approved for bloodborne pathogen use. A continuous observation of Nurse Aide (NA) #1 was conducted from 03/12/25 at 11:46 AM through 12:00 PM and revealed the following: On 03/12/25 at 11:46 AM Nurse Aide #1 was observed in Resident #58's room. She stated she needed to go to the medication cart and gather necessary supplies. When she returned to Resident #58's room she was observed with a glucometer in her hand, alcohol swabs, and a lancet (used to stick the resident's finger). While in the room a second glucometer was observed on Resident #58's bedside table, NA #1 stated the first glucometer on Resident #58's table would not scan his barcode (on the resident identification bracelet), so that was why she had to obtain the second glucometer from the medication cart. NA #1 obtained Resident #58's blood sugar with a reading of 135 at 11:48 AM. She then stacked the two identical glucometers on top of one another and threw away her trash, exiting the room with both glucometers in hand at 11:50 AM. Nurse Aide #1 went over to Resident #1 with both glucometers still in her hand and pushed the resident to her room. She told Resident #1 she was going to check her blood sugar and would be right back. Nurse Aide #1 then went to the medication cart and obtained alcohol swabs, a lancet, test strip and placed one of the glucometers onto the medication cart. NA #1 kept the other glucometer in her hand and scanned Resident #1's barcode. NA #1 was not observed disinfecting the glucometer and no disinfecting wipes were observed on the medication cart. At 11:54 AM Nurse Aide #1 entered Resident #1's room with one of the two glucometers that were in Resident #58's room. NA #1 began to obtain Resident #1's blood sugar, the surveyor stopped NA #1 and asked if the glucometer was the same glucometer used on Resident #58. NA #1 stated, No, I am using the glucometer that was laying on his table, not the glucometer I used to get his blood sugar. NA #1 obtained Resident #1's blood sugar which was 244 at 11:57 AM and exited the room at 11:58 AM. At 12:00 PM the surveyor asked to see the glucometer history for the machine used to obtain Resident #1's blood sugar. The glucometer history revealed on 03/12/25 at 11:48 AM a blood sugar reading of 135 was obtained and at 11:57 AM a blood sugar reading of 244 was obtained. NA #1 was observed taking the glucometer to the nurse's station and obtaining a purple top wipe. She wiped the glucometer front and back quickly and immediately placed it onto the docking station to charge. An interview occurred with Nurse Aide #1 on 03/12/25 at 12:00 PM. NA #1 stated she had taken one glucometer into Resident #58's room and sat it on his bedside table, however it would not scan so she had to go to the medication cart and obtain another glucometer. Once in Resident #58's room she had two glucometers and used one of them to obtain his blood sugar. She stated she placed both glucometers on top of one another and thought she had placed the one she used to obtain Resident #58's blood sugar on the medication cart however made a mistake and took it into Resident #1's room and also obtained Resident #1's blood sugar using the same machine without cleaning it in between residents. NA #1 stated she knew she was supposed to clean the glucometer in between residents and had been educated on it but just made a mistake. She also stated she knew there was a wet time for the cleaning of the glucometer and thought she had cleaned the glucometer for two minutes but did not time it. NA #1 stated she thought she could just let the glucometer air dry on the docking station. An interview on 03/12/25 at 12:53 PM with the Infection Preventionist (IP)/ Director of Nursing revealed each resident household had 2 glucometers to use because not all residents admitted into the facility had their own glucometer. She stated the facility was very strict on disinfecting glucometers in between use of each resident and had just provided education on glucometer cleaning and disinfecting in January 2025. The IP stated the nurses and nurse aides should be using the disinfectant wipes after each use of the glucometer with a wet contact time of 2 minutes using two wipes and wiping the entire surface of the glucometer. After that, the nurses and nurse aide were to lay the glucometer on a towel and let it dry for a duration of 2 minutes. She stated NA #1 should have known the policy on cleaning and disinfecting the glucometers and followed it. The IP stated the negative outcome that could have occurred from not disinfecting the glucometer between resident use included the spread of bloodborne pathogens. She stated there were two current residents in the facility with a bloodborne pathogen and they were located in the same neighborhood of Resident #58 and Resident #1. The IP stated the facility did not have dedicated glucometers for each individual resident because the staff had been provided with education and training on how to disinfect the glucometers per manufacturer's instructions. An interview conducted on 03/13/25 at 2:34 PM with the Nurse Practitioner (NP) revealed all nursing staff should be disinfecting the glucometers in between each resident and according to manufacturer's instructions. The NP stated there was a risk of spreading bloodborne pathogens by using the same glucometer on both residents without cleaning it per manufacturer instructions. She stated bloodborne pathogens could be spread by blood or bodily fluid if the nursing staff were not following standard precautions by cleaning the glucometer in between residents. She stated the risk of cross contamination could be high. An interview conducted on 03/13/25 at 3:03 PM with the Medical Director (MD) revealed he felt using the same glucometer on multiple residents was an issue Administration needed to look into, including why it happened and preventative measures. The MD stated the staff could not use the same test strip for the glucometer on more than one resident. The interview revealed he felt using a test strip on multiple residents was the only likely way a bloodborne pathogen could be spread. The MD stated the nursing staff should be disinfecting the glucometer as directed by the facility. An interview on 03/12/25 at 1:00 PM with the Administrator revealed that glucometers should be disinfected according to the manufacturer's instructions. The Administrator was notified of the immediate jeopardy on 03/12/25 at 3:30 PM. The facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; During an observation on 3/12/25 at 11:46 AM, the Nursing Assistant failed to follow the manufacturer's guidelines for cleaning and disinfection of one blood glucose meter used for Resident #58 and Resident #1. Following the observation, this glucometer was cleaned and disinfected based on manufacturer's guidelines by the Director of Nursing. This failure provides the high likelihood for the spread of blood borne pathogens in the facility. On 3/12/25, the Nursing Assistant was reeducated by the facility's Nurse Educator on the manufacturer's guidelines for cleaning and disinfecting blood glucose meters to include competency validation. On 3/12/25, the Nursing Assistant was provided competency validation by the Nurse Educator. On 3/12/25, 100% of the blood glucose meters were cleaned and disinfected based on manufacturer's guidelines by the Director of Nursing. The manufacturer's guidelines are as follows: put on clean gloves, clean the glucometer as below with Germicidal Disposable Wipes ([purple top] for all non-contact enteric isolation) or Bleach Germicidal Wipes ([orange wipes] if resident on contact enteric isolation) - Place the meter on a level surface and ensure meter has been powered off - Obtain appropriate wipe and squeeze excess liquid from wipe - Wipe the meter to clean by gently wiping the outside of the meter and carefully wipe around the test strip port area, making sure that no liquid enters the test strip port - Dry the meter thoroughly with a dry cloth or gauze. Visually verify that no solution is seen anywhere on the meter at the completion of cleaning - Use a fresh wipe to disinfect by gently wiping the outside of the meter three times horizontally and three times vertically and carefully wipe around the test strip port area, making sure that no liquid enters the test strip port. - Allow the surface of the meter to remain damp with the recommended contact time (two minutes for purple-top, 4 minutes for orange-top) - Dry the meter thoroughly with a dry cloth or gauze. Visually verify that no solution is seen anywhere on the meter at the completion of cleaning and disinfecting. - If further testing is not needed, return the meter to the base unit to charge the battery. On 3/13/25, Resident #58 and Resident #1 were evaluated by the Medical Director. On 3/13/25, the Resident #58 and Resident #1's responsible parties were notified of the infection control breach and provided information regarding the Medical Director's evaluation. On 3/13/25 the facility's Pharmacy Consultant conducted a 100% audit of all residents who require blood sugar checks and identified that thirty residents in the facility have the potential to be affected by the deficient practice. In addition, it was determined that two residents in the facility have a diagnosis of bloodborne pathogen. It was determined that both residents who have bloodborne pathogens do not have any blood sugar checks ordered and would not have any teammate use a blood glucose monitor to obtain any blood. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 3/12/25 facility took immediate action by having the Nurse Educator review the manufacture's guidelines and facility's cleaning grid for cleaning and disinfecting blood glucose meters to ensure that the guidelines were accurate and did not require changes. The Nurse Educator provided education to all current nursing staff (Nursing Assistants and Nurses) to follow the manufacturer's guidelines for cleaning and disinfection of blood glucose meters, for staff competency. Any current nursing staff who do not receive education by 3/13/25 (due to FMLA, leave, etc.) will be required to complete education prior to working a scheduled shift. All nursing staff hired after 3/13/25 will be required to complete this training and education upon hire. The education will be required annually. Beginning 3/12/25, the facility's Nursing Leadership team (Nurse Educator, Director of Nursing, Licensed Practical Nurse Unit Coordinators and Clinical Supervisors) will complete competency validation to monitor for compliance of all nurses and nurse aides following the manufacturer's guidelines for cleaning and disinfecting blood glucose meters. All currently employed nurses and nurse aides will have the competency validation completed by 03/13/25. Any employed nurses and nurse aides who have not received competency validation by 03/13/25 will receive competency validation by prior to their next working shift. All nursing staff hired after 03/13/25 will be required to complete the competency validation upon hire. On 3/13/25, the facility Administrator notified the local Health Department regarding the infection control breach. Alleged IJ Removal Date: 3/14/25 On 03/13/25, the credible allegation of immediate jeopardy removal was validated by onsite verification through facility staff interviews. The interviews revealed all nursing staff had received education on provided education to follow the manufacturer's guidelines for cleaning and disinfection of blood glucose meters. Nursing staff (Nurses and Nurse Aides) were asked by educators to provide demonstration of glucometer use and cleaning during the education. The facility's in-service log and training material was reviewed. Additional observations were conducted of nursing staff obtaining residents blood sugars and disinfecting the glucometer per manufactures instructions. The IJ removal date of 03/14/25 was validated.