Failure to Sanitize Reusable Equipment Between Residents
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices when a Charge Nurse did not sanitize a blood pressure cuff and pulse oximeter between use on two residents. Specifically, after taking the vital signs of one resident with multiple diagnoses including acute heart failure, COPD, and hypertension, the Charge Nurse placed the equipment back on the medication cart without sanitizing it. She then used the same unsanitized equipment to check the vital signs of another resident diagnosed with Alzheimer's disease, hypothyroidism, and hypertension. Interviews with the Charge Nurse, Assistant Director of Nursing, Director of Nursing, and Administrator confirmed that the expectation and facility policy require sanitizing reusable equipment between residents. The Charge Nurse admitted to forgetting this step and acknowledged the risk of cross-contamination. The facility's infection control policy, last revised in March 2024, specifies that reusable equipment must be appropriately cleaned and disinfected to prevent the transmission of disease and infection.