Failure to Maintain Aerosol Contact Precautions and PPE Use for COVID-19 Positive Residents
Penalty
Summary
The facility failed to implement proper aerosol contact precautions for residents who tested positive for COVID-19. Observations revealed that doors to isolation rooms, which were required to remain closed per facility policy and posted signage, were found open on multiple occasions. Staff members, including nursing assistants, were observed entering and exiting these rooms without wearing the required personal protective equipment (PPE), such as N95 respirators, gowns, gloves, and face shields. Specifically, one staff member was seen wearing only a surgical mask while exiting a COVID-19 isolation room, contrary to the posted instructions and facility policy. Interviews with staff, including nursing assistants, LPNs, the unit manager, and the director of nursing, confirmed that the expectation was for doors to remain closed and for staff to use appropriate PPE when entering rooms under aerosol contact precautions. Documentation showed that two residents had tested positive for COVID-19 and were admitted to the transitional care unit with orders for isolation and appropriate PPE use. Despite these protocols, staff did not consistently follow the required infection prevention and control measures, as evidenced by both direct observation and staff admissions during interviews.