Failure to Disinfect Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program as required, specifically in the disinfection of reusable resident care equipment. During a medication pass, a Certified Medication Aide (CMA) used a blood pressure cuff on two different residents without disinfecting it between uses. Observations showed that the CMA took the blood pressure cuff from the medication cart, used it on one resident, returned it to the cart without sanitizing, and then used the same cuff on another resident without cleaning it in between. The CMA stated in an interview that she cleaned the cuff at the start of her shift and twice during her shift, but also claimed to sanitize it between residents, which was not observed. The facility's policy requires non-invasive resident care equipment to be cleaned daily or as needed between use by nursing assistants, and immediately if visibly soiled. Interviews with the Regional Nurse and the Assistant Director of Nursing (ADON) confirmed that staff are trained and expected to disinfect reusable equipment between residents, in accordance with the facility's infection control policy. Both acknowledged that failure to do so poses a risk of cross-contamination. Record review of the facility's infection control policy further supported the requirement for cleaning equipment between resident use. The deficiency was identified through direct observation, staff interviews, and review of facility policy.