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F0880
D

Failure to Follow PPE and Hand Hygiene Protocols for Covid-19 Resident

Torrance, California Survey Completed on 06-13-2025

Penalty

Fine: $141,00024 days payment denial
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Certified Nursing Assistant (CNA 5) failed to follow proper infection prevention and control protocols when caring for a resident diagnosed with Covid-19. Specifically, CNA 5 entered the resident's room wearing only an N95 mask, without performing hand hygiene or donning a protective gown and face shield as required. CNA 5 proceeded to provide care and handle items in the resident's environment without the appropriate personal protective equipment (PPE) and without practicing hand hygiene before entry. The resident involved had a history of hemiplegia and hemiparesis following a stroke, severely impaired cognitive skills, and was dependent on staff for all activities of daily living. The facility's policy required staff to wear gloves, gown, N95 mask, and face shield, and to perform hand hygiene before entering the room of any resident on contact and droplet precautions due to Covid-19. Interviews with the CNA, Infection Preventionist Nurse, and RN Supervisor confirmed that the required infection control measures were not followed in this instance.

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