Failure to Conduct N95 Fit Testing for New Staff
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding N95 fit testing, as outlined in their document titled 'N95 Fit Testing.' This policy mandates that all employees must be fit tested for an N95 respirator upon hire and annually, in accordance with OSHA's Respiratory Protection Standard. However, one of the four sampled staff members, a Certified Nurse Assistant (CNA 4), was not fit tested upon hire. CNA 4 began working at the facility on February 3, 2025, and confirmed during an interview on February 25, 2025, that they had not been fit tested for the N95 mask. The Director of Staff Development (DSD) acknowledged during a concurrent interview and record review that CNA 4 should have been fit tested before starting work, as per the facility's policy. The Director of Nursing (DON) reiterated the requirement for fit testing upon hire and annually. The Infection Prevention Nurse (IPN) emphasized the importance of fit testing to prevent the transmission of airborne diseases between employees and residents. The failure to conduct the fit testing had the potential to result in the spread of COVID-19 and other airborne diseases within the facility.
Plan Of Correction
F 880 It is the policy of the facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicated disease and infections. Corrective Action for Resident found to have been affected by this deficiency: No Resident was identified to have been affected by this deficiency. Identification of Other Residents having the potential to be affected by the same deficient practice and corrective action that will be taken: All Residents have the potential to be affected by this deficiency. On 2/25/2025, the IP Nurse designee completed N95 Fit Testing for CNA 4. What measures will be put into place to ensure that the deficient practice does not recur: On March 14, 2025, the DON inserviced the IP LVN Designee on the facility's policy and procedure on N95 Fit Testing; including that all new hire employees must have N95 Fit Testing upon hire and before being assigned to work with any Resident(s) and annually thereafter. On February 25, 26, and 27, 2025, the IP LVN Designee completed an N95 Fit Testing Audit on all current Employees. There were no additional employees identified as not having been N95 Fit Tested upon hire. There were 15 current employees identified as not being current with annual N95 Fit Testing. On February 28, 2025, the IP LVN Designee completed N95 Fit Testing on the identified 15 employees. On March 14, 2025, the DON gave a 1:1 inservice to the IP LVN Designee on the facility's policy and procedures on N95 Fit Testing; including that all new hires must have N95 Fit Testing upon hire and before being assigned to any Resident(s), and annually thereafter. Measures that will be implemented to ensure that solutions are sustained: The IP LVN Designee will conduct monthly audits X 3 months on all new hire employees and all employees due for the prior months' annual N95 Fit Testing to ensure that all current employees are compliant with the facility's policy and procedures on N95 Fit Testing. Results of the monthly audits will be documented on the Quality Improvement Audit Tool. The documented results will be forwarded to the QA & A Committee monthly X 3 months for review and action planning as indicated or until the QA & A Committee determines compliance.