Failure to Follow Enhanced Barrier Precautions and Proper Linen Transport
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program as required by its own policies and national standards. Specifically, staff did not use proper personal protective equipment (PPE) when performing high-contact resident care activities. During an observation, a certified nursing assistant (CNA) entered a resident's room, where an Enhanced Barrier Precaution (EBP) sign was posted, and donned only gloves but not a gown before removing and emptying the resident's urinal. The resident in question had an open fracture of the right lower leg with an external fixator and was under physician orders for Enhanced Barrier Precautions due to the presence of an indwelling medical device. Additionally, staff failed to transport clean linens in a manner that would prevent the spread of infection. A CNA was observed removing clean linen from a hallway cart and carrying it pressed against her clothing while proceeding to a resident's room, instead of using a clean linen bag as required by facility policy. Interviews with staff and the Director of Nursing confirmed that these actions were not in compliance with established infection control procedures, including the use of gowns for high-contact activities and proper linen transport protocols.