Failure to Follow Infection Control Practices During COVID-19 Outbreak
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices during a COVID-19 outbreak affecting two halls. Used COVID-19 rapid tests were observed left on a bedside table near a facility exit and on top of the North Nurses Station, accessible to staff and residents passing by. Staff interviews confirmed that testing was supposed to occur in locked medication rooms, with used tests to be discarded immediately by a nurse, but this protocol was not followed. The Infection Preventionist acknowledged that the tests should not have been left in open areas and that the night nurse had left them out for an extended period. Additionally, signage for droplet precautions was found to be incorrect, with staff unable to see all necessary instructions, and the Infection Preventionist confirmed the signage did not meet expectations. Further observations revealed lapses in personal protective equipment (PPE) use and hand hygiene. A CNA was seen entering and exiting a room on droplet precautions without wearing a required face shield and failed to remove her N95 respirator before leaving the room. Another CNA was observed disposing of a used respirator and donning a new one without performing hand hygiene. The Infection Preventionist and other facility leaders stated that staff were expected to follow posted PPE guidelines and perform hand hygiene before donning clean masks, but these practices were not consistently followed. One resident involved had chronic obstructive pulmonary disease and was on special droplet precautions for COVID-19 at the time of the observed deficiencies.