Failure to Maintain Infection Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during a COVID-19 outbreak. Multiple resident rooms housing COVID-19 positive individuals were observed with doors left open, despite posted contact precaution signs indicating the need for closed doors. COVID-19 positive residents were seen outside of their isolation rooms, including one resident walking unassisted in the hallway and another seated in a wheelchair outside their room with their mask lowered below the nose and mouth. Staff interviews confirmed that these residents should have remained in their rooms under isolation, and that doors to COVID-19 rooms should have been kept closed to prevent the spread of infection. Additionally, a certified nurse assistant was observed inside an isolation room assisting a COVID-19 positive resident without wearing complete personal protective equipment (PPE). The trash receptacle for soiled PPE was not positioned near the exit door, requiring staff to cross the room to dispose of PPE, increasing the risk of contamination. After providing care, the CNA exited the isolation room without closing the door. The facility's own policy required exposed or symptomatic residents to remain in their rooms, staff to adhere to hand hygiene and PPE protocols, and isolation room doors to remain closed except when entering or exiting.