Failure to Use Required PPE During Linen Change in EBP Room
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to follow required infection control practices while changing linen in the room of a resident who was under Enhanced Barrier Precautions (EBP). The CNA was observed changing the linen without wearing a gown, which is required PPE for high-contact care activities in EBP rooms. The CNA acknowledged not wearing the gown and stated she should have worn both a gown and gloves during the task. The resident involved had a history of renal and ureteral calculous obstruction and had an indwelling catheter in place. Facility policy, as well as the Infection Preventionist, confirmed that gloves and a gown are required PPE when changing linen in EBP rooms, especially for residents with indwelling catheters. The failure to use appropriate PPE was directly observed and confirmed by both the CNA and the Infection Preventionist.