Failure to Disinfect Shared Blood Pressure Cuff Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain its infection prevention and control program by not cleaning shared patient-care equipment, specifically a blood pressure cuff, between use on two residents. On the observed date, Medication Aide (MA) A took the blood pressure of Resident #1, returned the cuff to the medication cart, and did not sanitize it. Later the same shift, MA A used the same unsanitized cuff to take the blood pressure of Resident #2 and again placed it back on the cart without cleaning. These actions occurred despite the facility’s written policy stating that when common-use equipment for multiple residents is unavoidable, it must be cleaned and disinfected before use on another resident. Resident #1 was a male resident with diagnoses including pneumonitis, type 2 diabetes mellitus, and hypertension. His most recent quarterly MDS showed a BIMS score of 09, indicating moderate cognitive impairment, and documented an active diagnosis of hypertension with no infections in the seven days prior to the assessment and no antibiotic use in the same period or since admission/entry. Resident #2 was a female resident with diagnoses including cerebral infarction, COPD, and hypertension. Her admission MDS documented a BIMS score of 00, indicating severe cognitive impairment, an active diagnosis of hypertension, and no infections or antibiotic use in the seven days prior to the assessment or since admission/entry. During interview, MA A acknowledged not sanitizing the blood pressure cuff between residents, explaining she was trying to locate residents and administer medications on time. She stated she previously used sanitizing wipes but they were not on her cart that day, and that in their absence she would sometimes use hand sanitizer on paper towels to clean the cuff. She also stated it was important to sanitize the cuff between residents because bacteria on the cuff could be carried from one resident to another. The DON stated that infection control staff and nurse managers were expected to perform skill checks, observations, and in-services for staff administering medications, that ADONs were responsible for daily monitoring of medication administration procedures, and that nurses and medication aides were responsible for restocking sanitizer wipes on the carts each shift. The DON and the Administrator both stated their expectation that staff use sanitizing wipes to clean blood pressure cuffs between residents and that failure to do so placed residents at risk for infections.
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