Failure to Implement Universal Source Control and PPE During Respiratory Outbreak
Penalty
Summary
The facility failed to follow state and local health authority guidance to control the spread of a respiratory infection, affecting all 142 residents. Observations revealed that a CNA entered a resident's room on contact and droplet precautions wearing only a surgical mask and gloves, stating she did not need a gown unless providing direct care. A rehab nurse was seen walking in the affected and unaffected wings without a mask, and an LPN was observed passing medication without a mask, only putting one on when addressed. Residents were brought to the main dining room for activities without masks. The facility's acute respiratory illness line list showed a significant outbreak, with 42 cases and 19 hospitalizations, and new symptomatic residents identified during the survey period. Interviews with the DON and ADON confirmed that appropriate PPE for contact and droplet isolation includes a gown, face mask, face shield, and gloves, and that all staff should wear masks in care areas. However, staff compliance was inconsistent. State and local health officials recommended universal source control, including masking for all residents, visitors, and staff, but the facility did not enforce resident masking, citing challenges due to illness and cognitive function. The facility's infection control policy lacked information on following state and local health department guidance during outbreaks.