Failure to Sanitize Shared Equipment Between Resident Uses
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices when a registered nurse did not sanitize shared use equipment, specifically a blood pressure device and wrist cuff, before and after use with two residents. During observation, the nurse used the same blood pressure device and wrist cuff on two different residents without cleaning the equipment between uses. The nurse later stated that she only sanitized the equipment every two people and had not been specifically trained by the facility to clean it between each resident. Interviews with the Assistant Director of Nursing, Director of Nursing, and Administrator confirmed that their expectation was for all shared use equipment to be sanitized before and after each resident use. The two residents involved had significant medical histories, including dementia, cerebrovascular insufficiency, depression, and other neurological and psychiatric conditions. Both residents required assistance with activities of daily living and used mobility aids such as wheelchairs and walkers. Review of facility policies indicated that standard precautions and infection control measures required cleaning non-invasive resident care equipment between uses, but these procedures were not followed during the observed incident.