Failure to Disinfect Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of an LVN who did not disinfect a blood pressure cuff between use on two residents. Observations showed that the LVN, who was an agency nurse filling in for an absent medication aide, did not sanitize the blood pressure cuff before, between, or after checking the blood pressure of two residents. The LVN acknowledged awareness of the need to disinfect equipment between residents but stated she was unfamiliar with the location of sanitizing supplies on the medication cart and did not ask for assistance before beginning her medication pass. Both residents involved were cognitively intact and had medical histories including hypertension, with care plans requiring regular blood pressure monitoring. The facility's policy, revised in September 2022, required that reusable resident-care equipment be cleaned and disinfected between residents according to CDC recommendations. Interviews with facility leadership confirmed that supplies were available and that the expectation for disinfection was clearly outlined in policy, but the LVN did not follow these procedures during her shift.