Failure to Sanitize Equipment and Perform Hand Hygiene Between Resident Contacts
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by observations of a medication aide (MA G) not sanitizing a blood pressure cuff and not performing hand hygiene before resident contact. Specifically, MA G obtained a blood pressure device from an unattended medication cart and used it on a male resident with encephalopathy, cerebral infarction, pneumonia, and diabetes mellitus type II, without sanitizing the cuff or device prior to use. Later, MA G used the same device on a female resident admitted for extended rehabilitative therapy following a femur fracture and with diabetes mellitus type II, again failing to sanitize the equipment and also neglecting to perform hand hygiene before resident contact. Interviews with MA G revealed she did not recall performing hand hygiene before contact with the second resident and assumed the blood pressure cuff was sanitized before use, later acknowledging that she should have sanitized it between uses. Both the Director of Nursing (DON) and the Administrator confirmed their expectations that staff perform hand hygiene and sanitize shared equipment between resident contacts, in accordance with facility policies and in-service training records, which MA G had attended. Facility policies reviewed emphasized the importance of hand hygiene before and after resident contact and the cleaning and disinfection of reusable resident-care equipment between uses.