Failure to Maintain Infection Control and PPE Protocols
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices within the facility. Staff members, including an activities leader, dietary aide, certified nurse aide, and nurse practitioner, entered and exited a room under contact and droplet isolation precautions for a resident with respiratory syncytial virus (RSV) without donning or doffing personal protective equipment (PPE) or performing hand hygiene. These staff members also failed to change masks, wear required face shields or goggles, and did not close the door as required. Some staff stated they did not notice the precaution signs or were unaware of the PPE requirements, despite the presence of posted signage and facility policy outlining these protocols. Additional deficiencies were observed during meal service, where staff, including an activities leader and an LPN, were seen placing their thumbs inside milk cartons while assisting residents, without wearing gloves or performing hand hygiene. The staff involved acknowledged that this was not appropriate practice, though one LPN claimed to have performed hand hygiene prior to the observation. These actions occurred during direct resident care and food handling, increasing the risk of contamination. A resident who tested positive for RSV was observed walking unmasked in the hallway and sitting in close proximity to other residents during meal times, with no staff intervention to encourage mask use or redirect the resident. The unit manager confirmed the resident's positive status and stated that attempts to have the resident wear a mask were unsuccessful. The facility's infection preventionist confirmed that all staff should use PPE when entering rooms under contact and droplet precautions, including when interacting with non-infected roommates.