How often do you think of diabetic testing as putting your residents at risk for acquiring a blood borne illness. Do your infection control policy and protocol contemplate safe and proper procedures for carrying out proper testing and medication administration for residents with diabetes? One of the many bases for issuing a survey citation to a skilled nursing facility is F Tag 441 – Infection Control. In particular, many facilities face citations at the immediate jeopardy level for mishandling blood glucose testing, including failure to change lancets or clean glucometers between patients, both simple and critical infection control measures in which to train your staff.
Facilities must have infection control programs in place. See 42 CFR § 483.65(a). Without proper infection control practices, blood glucose testing carries the potential for exposing residents (and staff) to blood borne pathogens, such as the hepatitis B virus. It should go without saying that needles, syringes, and even lancets used to obtain finger-stick capillary blood samples should never be reused. Additionally, if a glucometer must be used for more than one patient, the glucometer must be cleaned and disinfected in between patients. Not only is this expected by CMS when it comes time to survey a facility, but it is and has been clearly recommended by the CDC.
In its publication entitled Blood Glucose Monitoring and the Risk of Viral Hepatitis: Recommended Infection-Control and Safe Injection Practices to Prevent Patient-to-Patient Transmission of Blood borne Pathogens, the CDC issued several additional recommendations that should also be part of your facility’s diabetic infection control policy and staff training, including but not limited to:
- Assigning multidose insulin vials to individual patients and so labeling the vials
- Preparing insulin in a centralized medication area
- Disposing of sharps, including lancets, at the point of use (resident’s room) in a sharps container
- Decontaminating surfaces, such as glucometers, that are used among multiple patients after each use and any time contamination with blood/body fluids is suspected
- Keeping medication carts and clean supplies out of resident rooms, and refraining from using on another resident supplies and medications inadvertently taken to one resident’s bedside during blood glucose monitoring
- Wearing gloves during blood glucose monitoring and administration of insulin, changing gloves and washing hands in between residents, and properly disposing of gloves
- Implementing monitoring activities to identify residents with blood borne infections
- Offering of the hepatitis B vaccine to all direct care staff
- Training and observation of direct-care staff on aseptic technique and reporting of exposures.
You should be sure to use the CDC recommendations in developing your own facility’s infection control program policies and procedures. In addition to appropriate policies and procedures, your facility’s infection control program should incorporate the other elements outlined by the interpretive guidelines for F Tag 441 – a comprehensive infection control and prevention program that includes the above-mentioned policies and procedures, program implementation oversight activities (including a designated infection control coordinator), facility surveillance, education and training, reporting, antibiotic-use review, and adequate documentation of these efforts.
During a survey, under F Tag 441 the surveyors will evaluate whether your facility has an infection prevention and control program in place, uses that program to collect and analyze data; uses that data to implement a plan to prevent infections, evaluates staff practices for consistency with proper infection control practices; and appropriately prohibits contact between direct staff who have communicable diseases/open lesions and residents. Specifically, the interpretive guidelines instruct surveyors to observe whether glucometers are cleaned and disinfected appropriately after each use in resident care and whether single-use items such lancets are properly disposed of after one use. The guidelines for F Tag 441 specifically note that contaminated glucose monitoring devices, among other things, can indirectly transmit infection between residents, and that either disinfection or single-use disposables are necessary to prevent transmission. The guidelines even provide as a specific example of immediate jeopardy the failure to take the standard precautions by disinfecting glucometers after each use and using new lancets on residents during blood sugar testing, thereby potentially exposing residents to the spread of blood borne infections.
Thus, in developing your policies and procedures, training and educating staff, and performing oversight and surveillance activities in accordance with your facility infection control program, don’t overlook your residents with diabetes or practices related to blood glucose monitoring. Even more importantly, make sure that you are observing your direct-care staff periodically to ensure that they have not overlooked the risk of failing to use appropriate infection control practices in blood glucose monitoring.