Benefis Senior Services: Blood Glucose Safety Failures - MT

Federal inspectors observed the infection control failures during a complaint investigation at Benefis Senior Services - Grandview on August 12. Staff member C violated basic safety protocols while testing blood sugar levels for two residents, creating risks for bloodborne pathogen transmission.

The violations began at 7:37 a.m. when staff member C retrieved a portable glucose meter from a locked supply room. One minute later, she entered resident #3's room and put on gloves to perform blood glucose monitoring. She never sanitized her hands before putting on the gloves.

After testing resident #3's blood sugar, staff member C laid the glucose meter on a supply cart in the bathroom, removed her gloves, and washed her hands. She then carried the unwashed device to her medication cart and placed it on top.

Eight minutes later, staff member C entered resident #1's room and used the same glucose meter to test that resident's blood sugar. The device had never been cleaned between the two residents.

When finished, staff member C returned the glucose meter to the locked supply room and placed it on the charger. She never cleaned or sanitized the device after use.

Staff member C knew the proper procedures. When inspectors interviewed her later that morning, she stated the glucose meter should be cleaned with purple-top sanitizing wipes between each resident use and after use before returning it to the charger. She admitted she did not clean the device after each use, between residents, or before placing it back on the charger.

She also knew hand hygiene requirements. Staff member C told inspectors that hands should be washed or sanitized before putting on gloves and after removing them. She acknowledged she failed to perform hand hygiene before putting on gloves for resident #3's blood glucose monitoring.

Another staff member confirmed the facility's infection control requirements. Staff member B told inspectors the glucose meter should be sanitized between each resident's use and after the last resident's monitoring before replacing it on the charger. Staff member B also confirmed that hand hygiene should be performed before putting on gloves and after removing them.

The facility's own policy supported the staff members' statements about proper procedure. The Point of Care Testing Safety Manual, last revised in February 2024, explicitly stated that portable handheld testing devices must be disinfected after each patient use to prevent transmission of infection.

Blood glucose monitoring requires piercing the skin to obtain blood samples. When equipment is not properly sanitized between residents, bloodborne pathogens from one resident can potentially be transmitted to the next person tested with the same device.

The contaminated glucose meter was returned to the charger in the locked supply room, where other nursing staff would retrieve it for future blood sugar testing. This meant the infection control failure could affect additional residents beyond the two observed during the inspection.

Federal inspectors classified the violation as having minimal harm or potential for actual harm, but affecting few residents. The deficiency occurred under federal regulation F 0880, which requires nursing homes to provide and implement an infection prevention and control program.

The inspection was conducted in response to a complaint, though the specific nature of the complaint that triggered the federal investigation was not detailed in the inspection report.

Benefis Senior Services - Grandview must submit a plan of correction to address the infection control deficiencies. The facility has 14 days from when the inspection report is made available to make the findings and correction plan public, as required for nursing homes under federal regulations.

The glucose monitoring failures represent basic infection control breakdowns that nursing home staff are trained to prevent. Hand hygiene and equipment sanitization between residents are fundamental practices designed to protect vulnerable elderly residents from preventable infections and disease transmission.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Benefis Senior Services - Grandview from 2025-08-12 including all violations, facility responses, and corrective action plans.

Additional Resources

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