Failure to Disinfect Blood Pressure Cuff Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain its infection prevention and control program by not disinfecting shared blood pressure equipment between residents. On 02/13/2026 at 07:40 a.m., an LPN was observed taking one resident’s blood pressure prior to administering medications. After completing the blood pressure check, the LPN returned to the medication cart and placed the blood pressure cuff on the cart without sanitizing it. The LPN then administered medications to that resident. At 07:58 a.m. the same day, the LPN used the same blood pressure cuff to take another resident’s blood pressure, again returning the cuff to the top of the medication cart without disinfecting it. During a later interview, the LPN stated she forgot to wipe the blood pressure cuff between residents because she was nervous and acknowledged that failing to wipe the cuff with disinfectant wipes between residents was an infection control concern. She also stated that nursing staff received frequent training on hand hygiene and infection control. The first resident involved was an adult male with diagnoses including metabolic encephalopathy, essential hypertension, and paroxysmal atrial fibrillation, who was cognitively intact with no infections or antibiotic use noted in the seven days prior to the assessment. The second resident was an adult male with anemia, atherosclerotic heart disease, and essential hypertension, who was moderately cognitively impaired and also had no infections or antibiotic use in the seven days prior to the assessment. Facility leadership, including the ADON, DON, and Administrator, each stated in interviews that staff were expected to disinfect blood pressure cuffs between residents using disinfectant wipes and acknowledged that failure to do so was an infection control concern. The facility’s Infection Control Plan policy stated that the facility would establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of disease and infection.
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