Failure to Disinfect Reusable BP Wrist Cuffs Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an infection prevention and control program by not sanitizing reusable blood pressure (BP) wrist cuffs between residents. On the identified date, a medical assistant (MA) used two wrist blood pressure monitors (BPM #1 and BPM #2) to obtain BP readings for eight residents without disinfecting the wrist cuffs between uses. The facility’s own infection control plan required that reusable equipment be appropriately cleaned, disinfected, or reprocessed, and staff interviews confirmed that BP cuffs were expected to be sanitized between residents to prevent cross contamination. Surveyors observed the MA attempting to obtain a BP reading on one male resident using BPM #1, then immediately using the same device on another resident’s wrist without sanitizing the cuff. The MA then proceeded through a series of residents, using BPM #1 and BPM #2 on their wrists and repeatedly failing to sanitize the cuffs after each BP measurement. After each encounter, the MA washed and dried her hands before exiting the room, but no cleaning of the wrist cuffs was performed between residents. The residents involved had multiple medical diagnoses, including Parkinson’s disease, tremors, traumatic brain injury history, type 2 diabetes mellitus, chronic kidney disease stage 4, and essential (primary) hypertension. Their cognitive status ranged from no cognitive impairment (BIMS scores 14–15), to moderate impairment (BIMS 9), to severe impairment (BIMS 1), and some were unable to complete interviews. During an interview, the MA stated that the cuffs were sanitized between each resident only when residents had COVID, and showed the surveyor the wipes used for cleaning equipment. Other nursing staff, including LVNs and the DON, stated that BP cuffs must be sanitized between each resident to avoid cross contamination, underscoring that the observed practice did not follow facility policy or expected infection control procedures. This failure could place residents at risk of infection.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.