Failure to Follow Infection Control Protocols During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices among staff during a COVID-19 outbreak. Specifically, the Environmental Services Director (EVSD) did not perform hand hygiene after disposing of a cup for a resident in a room, as observed by the Infection Preventionist (IP). The EVSD acknowledged that not sanitizing hands could contribute to the spread of infections, and the IP confirmed that this lapse could result in infection transmission. Additionally, two other staff members, a Certified Nursing Assistant (CNA 2) and a Dietary Aide (DA 1), were observed not wearing the required N95 respirator masks during the outbreak. DA 1 was seen wearing a surgical mask in the kitchen and only switched to an N95 mask upon noticing the presence of the Director of Nursing (DON) and a surveyor. CNA 2, who was responsible for screening employees and visitors at the facility entrance, was also observed wearing a surgical mask instead of an N95 respirator. Both the IP and DON confirmed that all staff were required to wear N95 masks during the outbreak, and failure to do so could contribute to the spread of COVID-19. A review of facility policies indicated that hand hygiene and the use of appropriate personal protective equipment (PPE), including N95 respirators during outbreaks, were required. The facility's records also showed that the EVSD, CNA 2, and DA 1 had declined COVID-19 vaccination. The observations and interviews confirmed that staff did not consistently follow established infection control protocols, including hand hygiene and use of N95 respirators, as required by facility policy and public health guidance during the outbreak.