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 improper disinfection of reusable medical equipment. Specifically, a medication aide (MA) did not sanitize a blood pressure cuff before or after use when checking the blood pressure of three residents during a morning medication pass. This was observed as the MA moved from one resident to another, using the same blood pressure cuff without cleaning it between uses, despite the facility's policy requiring such equipment to be cleaned between residents. The MA later acknowledged awareness of the requirement but stated she forgot to sanitize the cuff between uses. The residents involved had various medical conditions, including elevated blood pressure, multidrug-resistant organism infection, wound infection, cerebrovascular accident, and type 2 diabetes mellitus. Their cognitive statuses ranged from severely impaired to intact. The facility's policy, revised in March 2025, clearly stated that non-critical items such as blood pressure cuffs must be kept clean, but this protocol was not followed during the observed incident.