Failure to Follow Infection Control Procedures for Soiled Linens
Penalty
Summary
A certified nursing assistant (CNA) failed to follow proper infection control procedures for two residents who required enhanced barrier precautions due to their complex medical conditions. For one resident with a history of sepsis, quadriplegia, tracheostomy, stage 4 pressure ulcer, and gastrostomy, the CNA did not place the resident's soiled Hoyer transfer sling and bed sheets in the designated linen barrel after use. Instead, these items were found stuffed inside the resident's bedside rubbish bin, wet and saturated with liquid. The licensed vocational nurse (LVN) and director of nursing (DON) confirmed that these linens did not belong in the trash bin and that improper handling could be a source of infection, especially given the resident's vulnerability. In a separate incident, the same CNA was observed in another resident's room, where a navy-blue blanket was found bundled on the floor at the foot of the bed. The resident, who had diagnoses including acute and chronic respiratory failure, colostomy, tracheostomy, gastrostomy, and peripheral vascular disease, was dependent on staff for all activities of daily living and also required enhanced barrier precautions. The CNA picked up the blanket from the floor, shook it out, and attempted to place it back on the resident's bed before being stopped by the surveyor. When questioned, the CNA acknowledged that the blanket could be placed in the dirty linen barrel but initially attempted to reuse it. Both residents were on enhanced barrier precautions due to their wounds and indwelling medical devices, as indicated by physician orders and facility policy. The facility's infection control policies required that soiled linens be handled in a manner that prevents contamination and the transfer of microorganisms. The CNA's actions in both cases did not comply with these procedures, as confirmed by interviews and observations documented in the report.