Failure to Disinfect Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices when a licensed vocational nurse (LVN) did not disinfect a blood pressure cuff between use on two residents. During a morning medication pass, the LVN checked the blood pressure of one resident and then immediately used the same cuff on another resident without sanitizing it before or after each use. This was observed directly by surveyors and confirmed in interviews with the LVN, who acknowledged that reusable medical equipment should be sanitized between residents to prevent cross contamination, but stated she forgot due to being new to the facility. Both residents involved had significant medical histories, including coronary artery disease, hypertension, diabetes, stroke, heart failure, and dementia, with varying levels of cognitive impairment as indicated by their BIMS scores. The facility's own infection control policy required that non-critical resident-care items, such as blood pressure cuffs, be cleaned and disinfected between residents. The Director of Nursing confirmed awareness of the incident and reiterated the expectation that all medical equipment be sanitized between uses.