Failure to Follow EBP, Handle Soiled Linen Properly, and Complete Annual TB Risk Assessment
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control program related to handling of soiled linen, adherence to Enhanced Barrier Precautions (EBP), and completion of the annual tuberculosis (TB) risk assessment. For one resident with acute and chronic respiratory failure with hypoxia, type 2 diabetes with hyperglycemia, chronic kidney disease stage 3, and mixed bladder incontinence, the resident reported placing soiled laundry on the floor in the corner of the room every day for staff to collect. On one occasion, housekeeping staff also picked up the resident’s wet soiled laundry and placed it directly on the floor in the same corner. A CNA later confirmed the laundry was saturated and had not been previously known to be on the floor, verifying that soiled linen was being stored on the floor of the resident’s room. The facility also failed to follow its own EBP policy for two residents who had orders for EBP. One resident with cerebral palsy, profound intellectual disabilities, seizures, hypertension, and dysphagia had an order for EBP and tube feeding via Isosource 1.5. An EBP sign and PPE (gown, gloves, goggles) were present at the room, and staff acknowledged the resident was on EBP. However, during incontinence care and tube feeding administration, the CNA and LPN only used hand hygiene and gloves and did not don gowns as required for high-contact care activities under EBP. Another resident with hemiplegia, type 2 diabetes, bladder dysfunction, hypertension, an indwelling urinary catheter, and ESBL colonization also had an order for EBP. During dressing, transfer with a sit-to-stand lift, and handling of the urinary catheter collection bag, two CNAs wore gloves but did not wear gowns, despite signage and available PPE and their acknowledgment that gowns should be used for EBP care. Additionally, the facility did not complete the TB risk assessment on an annual basis as required by its policy. Documentation showed a TB risk assessment was completed on one date in 2026, but there was no documentation that a TB risk assessment had been completed in 2025. The Infection Preventionist confirmed the absence of documentation for a 2025 TB risk assessment, despite the facility’s policy stating that a TB risk assessment shall be conducted annually to determine appropriate administrative, environmental, and respiratory protection controls based on the current TB risk classification.
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