Failure to Sanitize Reusable Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by the improper handling of reusable blood pressure cuffs for two residents. Specifically, a medication aide (MA A) was observed using the same reusable blood pressure cuff on two different residents without sanitizing it between uses. MA A admitted during an interview that he was not taught to clean the cuff between residents, though he acknowledged the risk of transferring bacteria. The observations were corroborated by interviews with multiple staff members, including assistant directors of nursing (ADONs), the director of nursing (DON), and the administrator-in-training, all of whom confirmed that blood pressure cuffs should be sanitized between residents to prevent cross-contamination and infection. The residents involved included one with a progressive neurological condition and hereditary motor and sensory neuropathy, who was noted to have increased susceptibility to infection due to nutritional deficiencies and dehydration, and another with non-traumatic brain dysfunction and dementia, requiring assistance with activities of daily living and having impaired cognition. Record reviews and staff interviews confirmed that the facility's policy required reusable equipment to be cleaned and reprocessed before being used on another resident, but this protocol was not followed in these instances.