Failure to Implement Infection Control Policies During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement its infection control policies and procedures during a COVID-19 outbreak, as evidenced by multiple observed lapses. Staff did not consistently wear N95 masks as required, with some personnel, including staffing coordinators, not wearing N95 masks despite the presence of COVID-19 positive staff and residents. One LVN was observed wearing an N95 mask over a surgical mask, which the infection preventionist confirmed defeats the purpose of the N95 by preventing a proper seal. Additionally, a CNA was seen leaving a resident's room while still wearing gloves, retrieving clean linen from a cart, and re-entering the room without removing or changing gloves, contrary to the facility's standard precautions policy. Further, the facility did not comply with local health department guidelines intended to contain the spread of COVID-19. These lapses included failure to maintain social distancing, not staggering communal activities, not separating laundry of exposed and non-exposed residents, and not keeping doors closed for residents exposed to COVID-19. Interviews with the infection preventionist and director of nursing confirmed that these guidelines were not followed, and that adherence to these protocols is essential for infection mitigation. Review of facility policies indicated that staff are to be educated and adhere to proper infection control techniques, including prompt glove removal and compliance with local masking requirements.