Failure to Follow Infection Control Protocols and Proper PPE Use
Penalty
Summary
Facility staff failed to adhere to infection prevention and control measures for five of nine sampled residents, as required by facility policy and CDC guidance. Specifically, staff did not consistently don full personal protective equipment (PPE), including N95 respirators, gowns, gloves, and face shields or goggles, before entering rooms of residents who were either COVID-19 positive or under transmission-based precautions due to exposure. Observations revealed that a certified nursing assistant entered the rooms of multiple residents wearing only an N95 mask, without a gown, gloves, or eye protection. Additionally, a housekeeping staff member was observed inside a COVID-19 isolation room wearing only a gown, gloves, and a surgical mask, without the required N95 mask or eye protection. These actions were in direct contradiction to both facility policy and CDC recommendations, which require full PPE for staff entering rooms of residents with suspected or confirmed COVID-19 infection. The residents involved had varying degrees of cognitive and physical impairment, with some being dependent on staff for most activities of daily living. Physician orders and care plans for these residents specifically indicated the need for transmission-based precautions due to either confirmed COVID-19 infection or exposure. Facility signage outside the affected rooms clearly indicated the need for contact and droplet precautions, including the use of gowns, gloves, and appropriate respiratory and eye protection. Despite these clear directives, staff interviews confirmed that the required PPE was not always used when entering these rooms. In a separate incident, a certified nursing assistant left a soiled diaper and dirty clothes on the floor in a resident's room, rather than immediately placing them in appropriate bags and hampers as required by facility policy. Staff interviews confirmed that soiled items should not be left on the floor due to the risk of contamination and cross-transmission. Facility policy mandates that all soiled laundry and personal items be handled as potentially contaminated and placed in designated containers at the point of use. The failure to follow these procedures was acknowledged by both the staff involved and the facility's infection preventionist.