Failure to Follow Infection Control Protocols During Linen Handling
Penalty
Summary
A Certified Nursing Assistant (CNA) was observed carrying clean towels, linen, a gown, and chux pads when a towel slipped from their hand and fell onto the floor. The CNA picked up the towel, mixed it with the remaining clean items, and proceeded toward a resident's room with the intention of using the contaminated towel on the resident. The incident was witnessed by a surveyor, and the CNA acknowledged that the towel had been on the floor and was about to be used for resident care, which is a violation of infection prevention protocols and facility policy. The contaminated items were subsequently discarded after the CNA was confronted. The resident involved had a complex medical history, including acute respiratory failure with hypoxia, a benign neoplasm of the meninges, acute kidney failure, and a tracheostomy. Interviews with facility staff, including a Licensed Vocational Nurse and the Infection Prevention Nurse, confirmed that using linen that had been on the floor poses a risk of infection, especially for immunocompromised residents. The facility's infection control policy specifies that any linen that comes into contact with the floor should be treated as contaminated and not used for resident care.