Failure to Follow Infection Control Practices During COVID-19 Outbreak and Transmission-Based Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by staff during a COVID-19 outbreak and in the care of residents on transmission-based precautions. Observations revealed that staff did not consistently use appropriate Personal Protective Equipment (PPE), such as N95 respirators, gowns, and gloves, as required by facility policy and posted signage. For example, an LPN was observed wearing a KN95 mask with ear loops instead of a fit-tested NIOSH-approved N95 respirator while entering and exiting a resident's room on Aerosol Contact Precautions for COVID-19. The same staff member was also seen in the hallway and entering other rooms with only a KN95 mask, despite being instructed to wear an N95 respirator during the outbreak. Additionally, signage instructed that resident room doors should remain closed for those on Aerosol Contact Precautions, but the doors were repeatedly observed open during multiple checks. A CNA was observed entering and working inside a resident's room on Aerosol Contact Precautions with the door left open, contrary to posted instructions. The CNA acknowledged awareness of the requirement to keep the door closed but stated it was not done due to being busy. Another CNA was seen making a bed for a resident on Enhanced Barrier Precautions (EBP) for a history of multidrug-resistant organisms without wearing a gown, despite signage and policy requiring gown and glove use for high-contact activities such as changing linens. The CNA confirmed knowledge of the need to use PPE in such situations but did not comply at the time of observation. A housekeeper was observed cleaning a room under Contact Enteric Precautions for a resident with a positive C. difficile diagnosis without wearing a gown, as required by posted signage and facility policy. The housekeeper later acknowledged the expectation to wear a gown in such circumstances. Interviews with supervisory staff, including the Infection Preventionist, Resident Care Manager, and Director of Nursing, confirmed that staff were expected to follow all posted precautions, including the use of appropriate PPE and keeping doors closed for residents on transmission-based precautions. However, these expectations were not consistently met during the survey observations.