Expired N95 Mask Use and Improper PPE Removal During COVID-19 Precautions
Penalty
Summary
The facility failed to ensure that N95 masks provided for staff and visitors were not expired, as observed on multiple isolation carts at the entrances of COVID-19 designated rooms and the lobby receptionist area. Both 3M and BYD brand N95 masks were found to be past their expiration dates. Staff assigned to these rooms were observed wearing the expired N95 masks, and visitors were encouraged to use them as well. Although the Administrator referenced CDC and Public Health guidance regarding the extended use of N95 masks beyond their shelf life, it was clarified that such use was only permitted during a declared emergency, which was not in effect at the time of the observation. Additionally, a licensed nurse was observed exiting a resident's room, who was on transmission-based precautions for COVID-19, without removing personal protective equipment (PPE) as required. The nurse was seen wearing an isolation gown, mask, and face shield while preparing medication outside the resident's room, and confirmed that the PPE should have been removed before exiting. The facility's infection prevention policy also specified that PPE must be doffed and discarded, and hand hygiene performed before leaving the patient room to contain pathogens.