Failure to Ensure Proper PPE Use and Doffing for Resident on Covid-19 Precautions
Penalty
Summary
The facility failed to ensure that staff properly donned and doffed personal protective equipment (PPE) when caring for a resident who was under transmission-based precautions due to a positive Covid-19 diagnosis. Observations revealed that a nursing assistant entered the resident's room without wearing required eye protection, and there was no eye protection available on the PPE cart outside the room. Additionally, the nursing assistant removed all PPE, including the N95 mask, before exiting the room, contrary to CDC guidelines which require the respirator to be removed after leaving the room. Other staff, including an LPN and another nursing assistant, were also observed doffing all PPE, including the N95 mask, inside the resident's room and stated they were unaware of the correct procedure. Interviews with staff indicated a lack of awareness or recall regarding the proper sequence for doffing PPE, specifically the requirement to remove the N95 mask after exiting the room. The nurse manager acknowledged that the doffing instructions were posted but noted the print was small and staff might not notice them. The director of nursing and a regional nurse consultant confirmed that staff had been trained on donning and doffing procedures but expected adherence to proper protocols. The facility's policy, consistent with CDC guidelines, was available but not effectively implemented by staff during the observed incidents.