Failure to Follow COVID-19 PPE and Hand Hygiene Protocols
Penalty
Summary
Staff failed to adhere to proper infection control protocols when caring for a resident who tested positive for COVID-19 and was placed on droplet precautions. A Certified Nursing Aide (CNA) entered the resident's room wearing only a surgical mask, gown, and gloves, but did not use required eye protection or an N-95 respirator as recommended by CDC guidance for confirmed COVID-19 cases. After attempting to feed the resident, the CNA removed her gown and gloves, handled the resident's tray, and performed additional tasks in other rooms before removing her mask and washing her hands in a bathroom down the hall, rather than performing hand hygiene immediately upon exiting the resident's room. The CNA confirmed she did not wash her hands before leaving the room and was unaware of the need for eye protection or an N-95 mask. Interviews with the CNA and the Director of Nursing (DON) revealed gaps in knowledge regarding appropriate PPE use and hand hygiene protocols for droplet precautions, particularly for residents with COVID-19. Facility policy required the use of masks and eye protection for droplet precautions and specified hand hygiene before leaving resident rooms. CDC guidance further specified the need for a NIOSH-approved N95 respirator, gown, gloves, and eye protection for staff entering rooms of residents with confirmed COVID-19. The facility had five residents positive for COVID-19 on the dementia care unit at the time of the survey, with the potential to affect other residents on the unit.