Expired N95 Fit Tests Among Staff During Outbreak
Penalty
Summary
The facility failed to ensure that all staff had up-to-date N95 respirator fit tests, as required by CDC and NIOSH guidelines. A review of the facility's Fit Test Log (FTL) revealed that 101 staff members had expired N95 fit tests, with 37 of those staff actively working during a specific shift while wearing N95 masks with expired fit tests. The Director of Nursing (DON) confirmed that they themselves had not been fit tested for the current year, and the last update to the FTL was provided to the Public Health Nurse due to a COVID-19 outbreak. The Assistant Director of Nursing (ADON) corroborated that 37 staff on duty were wearing N95 masks with expired fit tests. The Infection Prevention Nurse (IPN) stated that annual fit testing is necessary to ensure proper mask fit, especially in light of changes to staff members' facial structure or weight, and that expired fit tests could result in staff inhaling infectious particles during an ongoing outbreak. The facility was unable to provide a policy and procedure for annual N95 mask fit testing. Review of CDC and OSHA guidelines confirmed the requirement for annual fit testing for tight-fitting respirators, and the need for re-testing if there are changes in mask brand, model, or the employee's facial characteristics. The lack of current fit testing and absence of a policy contributed to the deficiency identified during the survey.