Failure to Ensure Proper N95 Mask Use, Fit-Testing, and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to use N95 masks correctly and did not receive timely fit-testing, as observed with four staff members. Staff were seen wearing N95 masks with both straps below the ears, with twisted straps, or with only one strap, and some staff reported not being trained on proper mask application. Two staff members, including an agency occupational therapist and a physical therapy intern, confirmed they had not been fit-tested at the facility before using N95 masks, despite working directly with residents. The facility's own policy required fit-testing before use and annually, but this was not followed for these staff. Additionally, the facility did not ensure Enhanced Barrier Precautions (EBP) were followed for a resident with a peripherally inserted central catheter (PICC) and wounds. There was no EBP signage or PPE cart outside the resident's room, and a certified nursing assistant assisted the resident with a transfer without wearing a gown and gloves, resulting in direct contact between the staff's clothing and the resident's gown. The staff member later acknowledged missing the requirement to use PPE for this resident, and the order for EBP had been in place for several days prior to the observation. Interviews with facility leadership confirmed that the expected practices were not followed. The infection preventionist and director of nursing both stated that staff should be fit-tested before using N95 masks and that EBP signage and PPE should be present and used for residents requiring these precautions. The failures were identified during a period when the facility had recently experienced a COVID-19 outbreak affecting residents and staff.