Failure to Clean Blood Pressure Cuff Between Resident Uses
Penalty
Summary
A medication aide (MA C) failed to clean a blood pressure cuff between uses, specifically before measuring the blood pressure of a resident with multiple comorbidities, including chronic kidney disease, heart failure, type 2 diabetes mellitus, hypertension, and a chronic non-healing wound. The resident was severely cognitively impaired and required significant assistance with daily activities. The aide used the same blood pressure cuff on another resident and then on this resident without cleaning it, as observed by surveyors. Interviews with the medication aide and the Director of Nursing confirmed that the blood pressure cuff should have been cleaned between uses to prevent possible infection, in accordance with the facility's policy on cleaning and disinfecting reusable items. The failure to follow infection control protocols was directly observed and acknowledged by staff, and the facility's policy required such equipment to be cleaned and disinfected between residents.