Failure to Properly Disinfect Shared Blood Pressure Cuffs Between Residents
Penalty
Summary
Surveyors observed that staff failed to properly clean and disinfect a shared blood pressure (BP) cuff between uses on multiple residents. On one occasion, a licensed nurse took the BP of a resident using a cuff from the medication cart, did not sanitize it after use, and then used the same cuff on another resident without cleaning it in between. The BP cuff was repeatedly placed back into the medication cart without being sanitized after each use. Another incident involved a different licensed nurse who, after taking a resident's BP, cleaned the cuff only with a small alcohol prep wipe before returning it to the cart. The infection preventionist later confirmed that the facility's expectation was to use a specific type of disinfectant wipe for cleaning BP cuffs between residents, and that using a small alcohol prep pad was not effective or acceptable for this purpose. Interviews with staff revealed a lack of awareness regarding the facility's policy on cleaning BP cuffs between resident uses. Review of the facility's policy indicated that reusable items are to be cleaned and disinfected or sterilized between residents, but this procedure was not followed as observed during the survey.