Failure to Follow COVID-19 Isolation and Infection Control Protocols
Penalty
Summary
The facility failed to follow established infection control procedures for a resident who was admitted with a diagnosis of COVID-19. The resident, who had moderately impaired cognition and required assistance with activities of daily living, was placed on droplet isolation. However, observations revealed that the resident's door was left open, and the resident was allowed to stand at the doorway and interact with another resident who was not wearing a mask. There was no isolation signage posted on or near the resident's room, and personal protective equipment (PPE) was found in disarray in the hallway, including dirty gowns in a laundry basket and on the floor, as well as used breakfast items placed on top of the dirty linen container. Staff interviews confirmed that the resident was on droplet isolation, but the required protocols were not being followed. The dietary aide and registered nurse both acknowledged the lack of isolation signage, the open door, and the resident's interactions with others at the doorway. The facility's policy required the door to remain closed and isolation signs to be posted, and the COVID-19 entry sign instructed staff to wear N95 masks, face shields, gowns, and gloves when entering the room. These procedures were not adhered to, resulting in a failure to maintain proper infection control for the resident with COVID-19.