Failure to Ensure Proper PPE Use for Resident on Transmission-Based Precautions
Penalty
Summary
A certified nursing assistant (CNA) failed to properly don the required personal protective equipment (PPE) before entering the room of a resident who was COVID-19 positive and on contact, droplet, and airborne precautions. The CNA entered the resident's room wearing gloves, a gown, and an N95 respirator over a surgical mask, but did not wear any eye protection or face shield as required by facility policy and CDC guidelines. The CNA remained in the resident's room for approximately ten minutes without the appropriate eye protection. The resident involved had multiple diagnoses, including chronic obstructive pulmonary disease, type 2 diabetes mellitus, and hypertensive heart disease, and was confirmed COVID-19 positive at the time of the incident. Facility records indicated that the resident was on isolation precautions, and signage on the resident's door specified the need for contact, droplet, and airborne precautions. The CNA stated she was trained to use an N95 mask but was not specifically instructed about not wearing a surgical mask underneath, and she was unaware of the need for eye protection, despite competency validation records indicating she had been trained in proper PPE use. Interviews with the infection preventionist and the director of nursing confirmed that the CNA did not follow facility policy regarding PPE use, specifically the requirement for eye protection and the correct use of the N95 respirator. Both staff members stated that appropriate PPE, including N95 masks and eye protection, was available and that staff had been trained on these procedures. The facility's policy required adherence to CDC-recommended infection prevention and control practices, including the use of appropriate PPE for residents on transmission-based precautions.