Failure to Implement and Maintain Infection Control Protocols During COVID-19 Outbreak
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program during a COVID-19 outbreak, as evidenced by multiple observations, interviews, and record reviews. Staff did not consistently follow infection control protocols, including the use of appropriate personal protective equipment (PPE) such as N-95 masks, face shields, or goggles when entering rooms of residents with confirmed COVID-19. PPE isolation carts were found to be missing required items, and staff were observed entering and exiting COVID-19 positive rooms without changing masks or performing hand hygiene due to lack of access to hand sanitizer. Additionally, signage indicating airborne isolation precautions was missing from the doors of several residents on isolation, and there was no signage at the facility entrance to alert staff and visitors to the outbreak status. Several residents with confirmed or suspected COVID-19, including those with severe cognitive impairment and complex medical histories, were not properly isolated or monitored according to facility protocols. For example, residents with active COVID-19 infections did not have appropriate isolation signage outside their rooms, and staff were observed providing care without the required PPE. In some cases, staff continued to wear the same masks after leaving COVID-19 positive rooms and provided care to other residents without changing masks or performing hand hygiene. Staff also reported not having access to necessary PPE, such as face shields or goggles, and hand sanitizer dispensers had been removed from the walls, further impeding proper infection control practices. The facility's leadership, including the Administrator, DON, and ADON, demonstrated a lack of awareness and oversight regarding the infection control protocols and the status of PPE and signage. Interviews revealed that the ADON was new and had not fully assumed responsibility for the infection control program, while the DON and Administrator were unaware of the deficiencies in PPE availability and signage. Additionally, residents who developed new signs and symptoms of COVID-19 were not promptly tested, contrary to facility policy. These failures were directly observed and confirmed through staff interviews, highlighting significant lapses in the facility's infection prevention and control measures during the outbreak.