Failure to Follow Enhanced Barrier Precautions and Proper Linen Handling
Penalty
Summary
Surveyors identified that the facility failed to maintain an effective infection prevention and control program, specifically in the areas of Enhanced Barrier Precautions (EBP) and linen handling. The facility's policy required the use of gown and gloves during high-contact care activities for residents with chronic wounds, in accordance with CDC guidance. On the day of survey, a resident with current pressure injuries and a care plan intervention for EBP was observed. Staff at the resident's bedside were not wearing the required PPE, and only donned gowns after being directed by the Administrator. Additionally, the PPE cart intended for EBP use was not positioned at the resident's room, but had been moved down the hallway, making it less accessible for staff compliance. Further observations revealed deficiencies in linen handling practices. A staff member was seen carrying soiled, loose clothing with a strong odor of urine down the hallway without placing it in a bag, contrary to the facility's policy that all used linen should be bagged at the point of use. The soiled clothing was later found unbagged in the dirty linen room. When questioned, a registered nurse stated that there were no bags available for the dirty linen. These actions and inactions demonstrate a failure to adhere to established infection control protocols, increasing the risk of communicable disease transmission.