Failure to Follow Enhanced Barrier Precautions During Linen Handling
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to follow Enhanced Barrier Precautions (EBP) when handling soiled linens for a resident with multiple diagnoses, including peripheral vascular disease, COPD, and cellulitis. The resident had severe cognitive impairment and required partial to moderate assistance with activities of daily living and mobility. Despite signage indicating EBP outside the resident's room and an active order for EBP, the CNA was observed removing soiled linen from the resident's bed and carrying it into the hallway without wearing a gown, as required by facility policy and EBP protocols. Interviews with the CNA and the Infection Preventionist confirmed that staff were expected to wear gloves and gowns during high-contact care activities, such as changing soiled linens, to prevent the spread of infection. The facility's policy specified that gowns and gloves must be used during these activities, but the CNA did not adhere to these requirements during the observed incident. This lapse in infection control practices constituted a failure to maintain the facility's infection prevention and control program.