Infection Control Deficiency: Improper Equipment Cleaning
Penalty
Summary
The facility failed to maintain an effective infection control program, specifically regarding the appropriate cleaning techniques for medical equipment. During a review of the facility's infection control policy, it was noted that the policy required all reusable equipment to be decontaminated and/or sterilized between residents at the point-of-care. However, observations during medication administration revealed that this policy was not being followed. On February 5, 2025, a Licensed Nurse and a Registered Nurse were observed using a sphygmomanometer to check the blood pressure of multiple residents without disinfecting the device between uses. The specific incidents involved Employee E6 and Employee E7, who both confirmed the failure to disinfect the sphygmomanometer after use on different residents. This oversight occurred during medication administration to Residents R9, R180, and R50. The lack of adherence to the infection control policy, as evidenced by these observations, indicates a deficiency in the facility's infection prevention and control program, as outlined in the regulatory requirements.
Plan Of Correction
1. R9, R180, and R50 experienced no ill effects from this event. E6 and E7 were immediately re-educated on the "Instrument Cleaning and Reuseable Equipment- Infection Control" and the requirement to decontaminate and/or sterilize reuseable equipment between residents at the point of care. The sphygmomanometers utilized were sanitized following this event. 2. The Director of Nursing or designee will audit the sanitization of reuseable equipment between residents during medication pass at the point of care of current residents to ensure compliance with the "Instrument Cleaning and Reuseable Equipment- Infection Control" by 2/28/25. 3. The Director of Nursing or designee will provide re-education to community staff on the "Instrument Cleaning and Reuseable Equipment- Infection Control" and the requirement to decontaminate and/or sterilize reuseable equipment between residents at the point of care by 3/10/25. 4. The Director of Nursing or designee will complete a random audit on up to 5 residents who require vital sign equipment to be utilized for medication parameters to ensure compliance with the "Instrument Cleaning and Reuseable Equipment- Infection Control" including the sanitization of reuseable equipment between residents weekly for 4 weeks and then monthly for 2 months. The results of these audits will be forwarded to the Quality Assurance Process Improvement team for review and recommendations.