Failure to Disinfect Reusable Scissors Between Wound Treatments
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection control policy for cleaning and disinfecting reusable, non‑critical equipment between residents. The written policy dated 1/1/2026 states that multiple‑resident use equipment shall be cleaned after each use. During surveyor observation, an LVN performed wound care on a resident with a left heel pressure ulcer. The LVN used a pair of scissors taken from her pant pocket to cut a special dressing (Calcium Alendronate) for the wound and then returned the uncleaned scissors to her pocket after completing the dressing change. No cleaning or disinfection of the scissors was performed after use on this resident. Shortly afterward, the same LVN performed wound care on the roommate, a resident with a diabetic ulcer on the right foot. The LVN again retrieved the same scissors from her pant pocket and used them to cut the special dressing for the second resident’s wound without having cleaned or disinfected the scissors between uses. The LVN then placed the scissors back into her pocket without cleaning them. In interviews, the first resident reported having heel wounds and receiving only sponge baths twice a week without being routinely offered washcloths for face and hand hygiene, and the second resident reported having a diabetic foot ulcer and needing to ask for basic care items such as washcloths. In a post‑observation interview, the LVN acknowledged forgetting to sterilize the scissors between residents and stated that the standard is to sterilize equipment between residents, and the Infection Preventionist confirmed that the expectation is to disinfect instruments between residents.
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