Failure to Implement Infection Control Protocols for COVID-19 Positive Residents
Penalty
Summary
The facility failed to follow infection control protocols for residents on transmission-based precautions for COVID-19. Specifically, two residents with confirmed COVID-19 diagnoses were not provided with trash receptacles in their rooms for the disposal of personal protective equipment (PPE), as required by facility policy. Staff, including CNAs, RNs, and housekeeping, reported that there was no designated place to discard used PPE in these rooms, leading them to dispose of PPE in hallway trash cans. Management and the infection preventionist confirmed that isolation rooms should have dedicated trash receptacles for PPE, but these were not present. Additionally, the facility did not maintain proper contact and droplet isolation for COVID-19 positive residents. One resident was observed using both their own bathroom, which was shared with other residents, and a communal rehab bathroom, contrary to orders and facility policy that called for a dedicated bathroom. There were no signs posted to redirect the resident to the appropriate bathroom, and staff were unaware of the cleaning schedules for these shared spaces. The infection preventionist and DON acknowledged the risk of infection spread due to improper bathroom use and lack of cleaning oversight. Furthermore, another resident on isolation for COVID-19 was observed leaving their room, interacting with other residents, and using a cloth mask instead of a required disposable mask. This resident was seen smoking outside near others and attending resident council while removing their mask and coughing. Staff confirmed that the resident was not supposed to be off isolation and should have been using a surgical mask and maintaining distance from others. These lapses in infection control protocols were observed and confirmed by multiple staff members, and were not in accordance with the facility's own policies and CDC guidelines.