GARRISON, ND - Federal inspectors cited Garrison Memorial Hospital Nursing Facility for failing to properly disinfect medical equipment between resident uses, documenting multiple violations of infection prevention protocols during a February 2025 inspection.
Equipment Disinfection Failures Put Residents at Risk
The inspection revealed that nursing staff repeatedly failed to sanitize stand lift devices after transferring residents, directly violating the facility's own infection control policy. Stand lifts are mechanical devices used to safely transfer residents with mobility limitations from beds, toilets, and wheelchairs.
On February 24, 2025, inspectors observed three separate instances where certified nursing assistants and nurses completed resident transfers without cleaning the equipment afterward. In one case, staff moved the unsanitized lift directly to another resident's room for immediate use.
The facility's written policy, dating from February 2011, clearly states that "all patient/resident multi-use medical devices must be disinfected between patient/resident uses," specifically including mechanical lift devices in this requirement.
Medical Significance of Equipment Cross-Contamination
Shared medical equipment represents a significant infection transmission pathway in healthcare settings. When lift devices contact residents' skin, clothing, and body fluids during transfers, they can harbor bacteria, viruses, and other pathogens. Without proper disinfection, these devices become vehicles for spreading infectious agents between vulnerable residents.
Nursing home residents face heightened infection risks due to age-related immune system changes, chronic medical conditions, and frequent use of antibiotics that can disrupt protective bacterial flora. Healthcare-associated infections in long-term care facilities can lead to serious complications including pneumonia, urinary tract infections, and bloodstream infections.
The Centers for Disease Control and Prevention identifies equipment cleaning and disinfection as fundamental infection prevention measures. Proper protocols require staff to clean visible soil from equipment surfaces and apply EPA-approved disinfectants according to manufacturer instructions between each resident use.
Staff Confusion About Responsibilities
The inspection revealed confusion among staff about equipment cleaning responsibilities. When questioned about sanitization protocols, one certified nursing assistant stated that "housekeeping does that," indicating a misunderstanding of immediate disinfection requirements.
Administrative records showed that housekeeping staff cleaned lifts twice monthly as part of routine maintenance. However, this scheduled cleaning does not replace the requirement for immediate disinfection after each resident contact.
An administrative staff member acknowledged that staff should clean equipment after each use, and the facility's administrative nurse confirmed this expectation during interviews. The disconnect between policy knowledge at the management level and practice at the bedside represents a significant gap in infection control implementation.
Industry Standards for Equipment Disinfection
Healthcare facilities must maintain comprehensive infection prevention programs that include specific protocols for shared equipment. Standard practice requires immediate cleaning and disinfection of any device that contacts multiple residents, regardless of the apparent level of contamination.
Proper lift disinfection involves several steps: removing visible debris, applying appropriate disinfectant solution, allowing sufficient contact time for pathogen elimination, and documenting the cleaning when required. Staff should receive regular training on these procedures and have easy access to cleaning supplies and disinfectants.
The facility's policy correctly identified lift devices as requiring disinfection between uses, aligning with established healthcare standards. However, the observed practices demonstrated that written policies alone do not ensure compliance without adequate staff education, supervision, and accountability measures.
Regulatory Response and Resident Protection
Federal inspectors classified this violation as causing "minimal harm or potential for actual harm," affecting few residents. However, infection control lapses can escalate quickly in congregate care settings where residents live in close proximity and share common areas and staff.
The inspection findings require the facility to develop and implement a plan of correction addressing the identified deficiencies. This typically includes reviewing current practices, retraining staff on proper procedures, implementing monitoring systems to ensure compliance, and documenting corrective actions.
Effective infection prevention requires consistent implementation across all staff levels and shifts. Facilities must establish clear expectations, provide necessary resources, and maintain ongoing oversight to ensure that infection control measures protect resident health and safety.
The documented violations at Garrison Memorial Hospital Nursing Facility highlight the critical importance of translating written infection control policies into consistent bedside practices that safeguard vulnerable nursing home residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Garrison Mem Hosp Nsg Fac from 2025-02-27 including all violations, facility responses, and corrective action plans.
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