Failure to Follow Enhanced Barrier Precautions and Proper Linen Handling
Penalty
Summary
Staff failed to maintain proper infection control practices for a resident who was under enhanced barrier precautions (EBP) due to a tracheostomy, gastric tube, and wounds. During an observation, a certified nurse aide (CNA) provided perineal care to the resident while only wearing disposable gloves and did not don a required disposable gown. The CNA stated she was unaware of the need to wear a gown during incontinent care for this resident, despite the physician's order specifying EBP for activities such as dressing, bathing, transferring, changing linen, providing hygiene, and toileting assistance. Additionally, soiled linen contaminated with feces was observed placed directly on the floor in the resident's room, rather than being properly bagged as required by facility policy. The resident involved was non-verbal, dependent on staff for bed mobility and toileting, and had significant medical conditions including cerebral infarction, aphasia, hemiplegia, and a tracheostomy. Facility policies provided by the clinical nurse consultant confirmed the requirements for gown and glove use during high-contact care and proper handling of soiled linens to prevent infection transmission.