Failure to Follow Infection Control Practices During COVID-19 Outbreak
Penalty
Summary
The facility failed to follow infection prevention and control practices in several key areas during a COVID-19 outbreak. Four out of five rooms designated for residents with COVID-19 had their doors left open, despite signage indicating enhanced airborne precautions requiring doors to remain closed. Staff interviews confirmed awareness of the requirement to keep doors closed, and the Infection Preventionist acknowledged that open doors could contribute to the spread of infection. Facility policy and CDC guidance both require doors to be closed for residents on airborne precautions. A Certified Nursing Assistant (CNA) did not perform hand hygiene after touching resident care areas and before serving food to a resident in a COVID-19 isolation room. The CNA donned gloves without prior hand hygiene and handled food and room surfaces with the same gloved hands. There were no hand hygiene supplies available outside the room. Facility policy requires hand hygiene before and after donning or doffing gloves, and staff interviews confirmed this expectation. Additionally, a resident who was positive for COVID-19 and coughing up phlegm did not have hand hygiene supplies within reach, making it difficult to clean his hands after coughing. The only available hand sanitizer was mounted on the wall approximately 12 feet away, and staff acknowledged that the resident was not expected to get out of bed to use it. In another instance, a resident receiving oxygen therapy had oxygen tubing that was not labeled and was found on the floor, kinked and stuck under a garbage can. Staff confirmed that tubing should not touch the floor and should be secured or wrapped if too long, as per facility policy.