DURHAM, NC - Federal health inspectors issued an immediate jeopardy citation to Carver Living Center after discovering serious infection control failures involving blood glucose monitoring equipment that potentially exposed vulnerable residents to bloodborne pathogens.
Critical Infection Control Breakdown
The February 7, 2025 federal inspection revealed that nursing staff failed to properly disinfect shared blood glucose meters between residents, creating a significant risk for disease transmission. Inspectors documented that an agency nurse used a blood glucose meter designated for one resident on another resident without proper disinfection procedures.
The violation occurred in a facility housing 18 residents with known bloodborne pathogens, making the infection control failure particularly concerning. Blood glucose meters can become contaminated with blood during routine testing and require specific cleaning and disinfection protocols between each use to prevent cross-contamination.
According to federal regulations, shared medical equipment must be cleaned and disinfected with EPA-registered disinfectants following manufacturer instructions. The failure to follow these protocols can lead to the transmission of serious infections including hepatitis B, hepatitis C, and HIV.
Inadequate Staff Training Revealed
The inspection uncovered systemic problems with staff orientation and training. The agency nurse involved in the violation was working his first week at the facility and reported receiving only a basic orientation packet that contained no information about glucose meter disinfection protocols.
When interviewed, the nurse stated he was unaware of facility policies for glucometer disinfection and did not know which products were approved for the process. A second agency nurse also reported she had not received orientation and was unfamiliar with required wet contact times for disinfectant effectiveness.
The facility's Director of Nursing acknowledged that agency nurses received only a basic information packet covering general guidelines, admission procedures, and documentation expectations. No specific training on infection control procedures for medical equipment was provided to temporary staff.
"It was assumed that agency nurses had received training to ensure their overall competency to care for residents prior to being hired," the Director of Nursing told inspectors.
Medical Risks of Contaminated Equipment
Blood glucose meters come into direct contact with blood during testing, making proper disinfection critical for preventing disease transmission. When equipment is not properly cleaned between patients, microscopic amounts of blood can remain on surfaces and potentially transmit bloodborne infections.
Hepatitis B can survive on surfaces for up to seven days, while hepatitis C can remain viable for several weeks under certain conditions. For elderly nursing home residents with compromised immune systems, exposure to these pathogens can result in serious illness or death.
The Centers for Disease Control and Prevention has documented multiple outbreaks in healthcare facilities linked to improper glucose meter hygiene. A 2012 outbreak at a New Hampshire hospital infected at least 30 patients with hepatitis C due to contaminated glucose monitoring equipment.
Additional Medication Safety Concerns
Beyond the immediate jeopardy citation, inspectors identified a medication error rate of 8 percent during their observation - well above the acceptable threshold of 5 percent. Two residents received incorrect medications due to nursing staff failures to verify proper dosages.
In one case, a resident received a combination laxative medication containing both sennosides and docusate when only sennosides was prescribed. The nurse had multiple options available on the medication cart but selected the wrong formulation.
A second medication error involved administering a calcium and vitamin D supplement with higher concentrations than prescribed. The resident was ordered 500 mg calcium with 200 units of vitamin D but received 600 mg calcium with 400 units of vitamin D instead.
These medication errors reflect broader concerns about medication safety protocols and staff attention to detail during the administration process.
Documentation Deficiencies Identified
Inspectors also cited the facility for maintaining inaccurate medical records in multiple areas. A resident's documented medication allergies to aspirin and Compazine were not properly transferred from hospital records to the facility's electronic medical record system.
Additional documentation problems included failure to properly record pain medication administration and missing documentation for a resident who left the facility against medical advice. These record-keeping failures can compromise patient safety and continuity of care.
Facility Response and Corrective Actions
Upon notification of the immediate jeopardy finding, facility administrators implemented comprehensive corrective measures. All licensed nurses, including agency staff, must now complete glucometer training and demonstrate competency before performing blood glucose monitoring.
The new protocol requires nurses to clean equipment first to remove visible contamination, then disinfect with a second wipe while maintaining a three-minute wet contact time for effective disinfection. Individual plastic storage bags for each resident's equipment prevent cross-contamination during storage.
Direct observation by nursing management is now required for competency validation, covering proper hand hygiene, correct disinfection technique, appropriate contact time monitoring, and proper storage procedures. No blood glucose monitoring is permitted until competency is validated and documented.
The facility's Medical Director, when contacted about the violations, stated this was the first time she had heard of such problems occurring and emphasized that "glucometer disinfection required better learning or training for all staff."
Regulatory Oversight Continues
Federal inspectors validated the facility's corrective actions on February 6, 2025, after observing proper infection control practices and interviewing nursing staff about the new protocols. All nurses demonstrated competency in glucometer disinfection and proper storage procedures during the follow-up inspection.
The immediate jeopardy status was officially removed on February 6, though the facility remains under heightened scrutiny. Medicare and Medicaid regulators will continue monitoring compliance with infection control standards and medication safety protocols.
For families with loved ones in nursing homes, this case highlights the importance of asking about infection control procedures during facility visits. Proper disinfection of medical equipment is a fundamental safety requirement that protects vulnerable residents from preventable infections.
The complete inspection report provides additional details about the violations and corrective measures implemented at Carver Living Center.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carver Living Center from 2025-02-07 including all violations, facility responses, and corrective action plans.
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