Failure to Implement Comprehensive Infection Control Measures During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, resulting in multiple deficiencies. Surveyors found that the facility did not conduct facility-wide COVID-19 testing as advised by the local Health Department during an outbreak. Only residents and staff in one section (Team 3) were tested, while those in another section (Team 4) were not, and only symptomatic or exposed staff were tested. The facility leadership stated they did not review the Health Department's email with the testing guidance until after the surveyors' inquiry. Observations revealed improper use of personal protective equipment (PPE) by staff, including a housekeeper who did not fully secure her gown, failed to change gowns and masks between isolation rooms, and did not perform hand hygiene when changing gloves. Additionally, residents were not offered hand hygiene before meals in the dining hall, contrary to facility policy. Medical equipment, such as a nebulizer mask, was found stored unsanitarily next to a soiled urinal in a resident's room. Several residents with COVID-19 or exposed to COVID-19 were not properly isolated or encouraged to follow infection control protocols. One resident with a positive COVID-19 test was observed leaving her room without a mask and using a community water fountain, while her room door was left open despite care plan instructions. Another resident, who was a roommate of a COVID-19 positive individual, was allowed to eat in the dining room without a mask and without staff intervention. Staff confirmed that care plans and infection control measures were not consistently followed.