Failure to Ensure Proper Use of N95 Masks During Covid-19 Outbreak
Penalty
Summary
Staff at the facility failed to implement and maintain an effective infection prevention and control program as required by both facility policy and CDC guidance. Despite two staff members testing positive for Covid-19, multiple staff—including a Restorative Aide, Nursing Assistant, Hospitality Aide, LPN, and the Administrator—were observed wearing N95 masks incorrectly, with the bottom strap hanging below the chin rather than secured at the nape of the neck. This improper use of N95 masks prevented a proper seal, which is necessary for effective respiratory protection. Staff interviews confirmed that, although they had received training on proper PPE use, they were not consistently following the correct donning procedures for N95 masks. Facility policies and CDC guidance reviewed in the report clearly outlined the correct method for donning N95 respirators, including the placement of both straps and the importance of achieving a tight seal. Observations and interviews revealed that staff were aware of the requirement to wear N95 masks after exposure to Covid-19 positive individuals, but failed to adhere to these protocols in practice. The deficiency was identified through direct observation, staff interviews, and review of training and policy documents, with no mention of corrective actions or follow-up at the time of the report.