Oregon DHS Aging and People with Disabilities

Scope/Severity

1

Visit Date : 12/9/2020

Corrected Date : N/A

There are no detail notes for this visit.

2

Visit Date : 1/19/2021

Corrected Date : N/A

There are no detail notes for this visit.

Scope/Severity

1

Visit Date : 12/9/2020

Corrected Date : N/A

There are no detail notes for this visit.

2

Visit Date : 1/19/2021

Corrected Date : N/A

There are no detail notes for this visit.

Scope/Severity

L2 Pattern

1

Visit Date : 12/9/2020

Corrected Date : 1/7/2021

Based on interview, observation and record review it was determined the facility failed to follow manufacturer's recommendations for glucometer (a blood sugar monitoring device) disinfection for 1 of 2 halls reviewed for infection control. This placed residents at risk for infections. Findings include:

Manufacturer care instructions for the Assure Prism Multi Blood Glucose Monitoring System indicated the following:
- The cleaning procedure is needed to clean dirt as well as blood and other body fluids on the exterior of the meter and lancing device before performing the disinfection procedure. The disinfection procedure is needed to prevent transmission of blood-borne pathogens
- The meter should be cleaned and disinfected after use on each patient
- Two disposable wipes will be needed for each cleaning and disinfecting procedure: one wipe for cleaning and a second wipe for disinfecting

On 12/8/20 at 11:56 AM Staff 3 (RN) was observed to exit room N33D (North Hall) with an Assure Prism Multi Blood Glucose Monitor (glucometer), went to the medication cart and immediately placed the glucometer in a drawer. When asked if the glucometer was cleaned Staff 3 stated it was cleaned with an alcohol swab after leaving the room and between each resident.

In an interview on 12/8/20 at 1:46 PM Staff 3 clarified the cleaning and disinfection process she followed for the glucometer was to use one alcohol swab to wipe down the glucometer after use on each resident, stated this one swab was used to both clean and disinfect the glucometer.

In an interview on 12/8/20 2:34 PM Staff 2 (DNS) reviewed the reported cleaning process and stated the use of one alcohol swab to clean and disinfect the glucometer between residents was not an appropriate practice.

All nurses were educated on proper procedure for cleaning and sanitizing of CBG machines. Continued ongoing education will be conducted by IP/SDC/DON upon hire of new nurses and at least quarterly to ensure ongoing knowledge. Residents with CBG checks will be reviewed for potential infectious process related to deficient practice. Random audits of residents with CBG checks will be conducted to ensure machines are being cleaned and sanitized per manufactures guidelines. Audits will be weekly x 4 weeks then monthly x 3 months then as needed. If during audits it is identified the facility failed to clean and disinfect glucometers per manufacture recommendations, the facility will assess and monitor affected resident(s) for signs and symptoms of infection. Results of audits will be presented to QAPI committee x 3 months to review and make changes as needed to current plan.

2

Visit Date : 1/19/2021

Corrected Date : N/A

There are no detail notes for this visit.

Scope/Severity

1

Visit Date : 12/9/2020

Corrected Date : N/A

There are no detail notes for this visit.

2

Visit Date : 1/19/2021

Corrected Date : N/A

There are no detail notes for this visit.

Scope/Severity

1

Visit Date : 12/9/2020

Corrected Date : N/A

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OAR 411-086-0330 Infection Control and Universal Precautions

Refer to F880

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2

Visit Date : 1/19/2021

Corrected Date : N/A

There are no detail notes for this visit.