Failure to Disinfect Shared Medical Equipment Between Residents
Penalty
Summary
Staff on two units failed to follow established infection control practices for cleaning and disinfecting medical equipment between resident uses. On the 100s unit, two CNAs were observed taking vital signs from multiple residents using a portable vital signs machine without disinfecting the equipment between each resident. Both CNAs acknowledged during interviews that they either did not clean the machine between residents or only cleaned it after completing all rounds, despite being aware of the policy requiring disinfection between each use. The facility's policy specified that disinfecting wipes should be used to clean all equipment used by multiple residents, including thermometers, blood pressure cuffs, and pulse oximetry monitors. On the 400s unit, similar lapses were observed with both the vital signs machine and the glucometer. A nurse was seen using the portable vital signs machine for a resident on Enhanced Barrier Precautions and then for another resident without disinfecting the equipment in between. The nurse admitted to not having cleaning wipes available and not disinfecting the machine as required. Additionally, another nurse was observed checking blood glucose levels for multiple residents using a shared glucometer without cleaning or disinfecting the device between uses. The nurse incorrectly stated that hand sanitizer was used for cleaning the glucometer and admitted to forgetting to disinfect it between residents. Interviews with the Infection Preventionist and Unit Manager confirmed that the facility's policy required the use of specific germicidal wipes for cleaning both the vital signs machine and glucometer between each resident use, with a specified contact time for disinfection. The observed staff did not follow these procedures, and the required cleaning agents were not always readily available on the units.