Failure to Use Required PPE When Entering COVID-19 Isolation Room
Penalty
Summary
A Certified Nursing Assistant (CNA) entered the room of two residents who had tested positive for COVID-19 without wearing the required personal protective equipment (PPE), which included a gown, N-95 respirator, face shield, and gloves. The CNA was observed wearing only a surgical mask despite clear signage posted at the room entrance specifying the necessary PPE for entry. The CNA acknowledged awareness of both the residents' COVID-19 status and the PPE requirements, and confirmed that appropriate PPE was available near the room door. The CNA stated uncertainty as to why the proper PPE was not worn and admitted understanding the risk associated with this action. The two residents involved had significant medical histories, including cerebral infarction, kidney cancer, anxiety disorder, osteoarthritis, and anemia. Both had recently tested positive for COVID-19, as documented in their medical records. The facility's Infection Preventionist confirmed that the expectation was for staff to perform hand hygiene and wear the required PPE when entering isolation rooms for COVID-19 positive residents, in accordance with facility policy. The Infection Preventionist acknowledged that the facility's policy was not followed in this instance.