Failure to Disinfect Shared Vital Signs Equipment Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff adhered to its infection prevention and control program and equipment cleaning policy when multiple residents tested positive for rhinovirus within a four-day period. The facility’s policy titled “Equipment Cleaning Guidelines,” last reviewed in May 2022, required that medical equipment used in a patient room or that comes into contact with the patient or the contaminated environment be cleaned and disinfected before being used on any other patient. Despite this policy, staff were observed not disinfecting a shared electronic vital signs machine between residents. Three residents with complex medical conditions were involved. One resident, admitted with a history including Trisomy 21, cerebral palsy, global developmental delay, seizures, GJ-tube dependence, chronic respiratory failure with tracheostomy/ventilator dependence, and recurrent aspiration pneumonia, developed initial symptoms of fever, increased secretions, and increased oxygen needs. A nasopharyngeal specimen collected later tested positive for rhinovirus. A second resident, with a history including extreme prematurity at 24 weeks’ gestation, tracheobronchomalacia, tracheostomy tube placement, ventilator dependence, and gastrostomy tube dependence, developed rhinorrhea, labored breathing, cough, wheezing, and increased oxygen demand; this resident’s nasopharyngeal specimen also tested positive for rhinovirus. A third resident, with a history of hypoxic-ischemic encephalopathy after a near-drowning event, tracheostomy tube placement, gastrostomy tube placement, and tracheostomy/ventilator dependence, had elevated blood pressure readings and underwent nasopharyngeal testing as part of a differential diagnosis, which also returned positive for rhinovirus. During the Infection Preventionist’s investigation into a common factor among the three residents, the use of a common electronic vital signs machine was identified as the shared element. The Infection Preventionist stated that staff were observed not disinfecting this vital signs machine between resident uses, contrary to facility policy. A CNA confirmed in interview that, prior to the rhinovirus outbreak involving these residents, they did not disinfect the vital signs machine between residents, despite acknowledging the importance of doing so to prevent the spread of illness.
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