Failure to Implement COVID-19 Transmission-Based Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program to prevent the transmission of communicable diseases, specifically COVID-19. During a COVID-19 outbreak, 16 residents on the third floor south tested positive for the virus. According to facility policy, residents with confirmed or suspected COVID-19 infections were to be placed on Aerosol Contact Precautions (ACP), which included placing signage on the resident's door to inform staff and visitors of required Personal Protective Equipment (PPE) and actions to take before entering. However, observations revealed that four rooms housing COVID-19 positive residents did not have the required ACP signage on their doors. Interviews with staff, including the Infection Control Preventionist, LPN, and DON, confirmed that ACP signage was expected to be present and that staff were required to wear PPE when entering the rooms of isolated residents. Despite this, there was no specific staff member assigned to routinely monitor for ACP signage or staff use of PPE, with oversight being shared among all managers and the Infection Control Preventionist. The lack of proper signage and monitoring led to a failure in fully implementing the facility's infection control protocols as outlined in their policy.