Failure to Ensure Staff Compliance with PPE Protocols for Resident on Droplet Precautions
Penalty
Summary
A deficiency occurred when staff failed to follow established infection prevention and control protocols for a resident who was on droplet precautions due to a COVID-19 diagnosis. On the morning of 11/12/25, electronic monitoring footage showed a staff member entering the resident's room without donning any personal protective equipment (PPE), placing a meal tray on the bedside table, interacting with the resident, and then exiting the room. This was despite clear signage on the door indicating droplet precautions and the presence of a PPE supply bin outside the room. The resident's care plan specifically required isolation with droplet precautions, including proper donning and doffing of PPE when entering and exiting the room. Interviews with facility staff, including the Infection Preventionist, ADONs, DON, and the administrator, revealed inconsistencies and uncertainty regarding the frequency and timing of staff reeducation on infection control practices. While staff members acknowledged the importance of donning PPE before entering and exiting rooms under droplet precautions, several were unable to recall when the most recent infection control training or in-service had occurred. The Infection Preventionist and other leaders stated that oversight was conducted through rounds and periodic competencies, but could not provide specific details or documentation of recent staff education on infection control. Additionally, the facility was unable to provide the requested infection control policy to the surveyor before the exit. The resident involved had a history of dementia, weakness, and COVID-19, and was assessed as having severe cognitive impairment. The failure to ensure staff compliance with PPE protocols, as well as the lack of clear documentation and timely reeducation on infection control, contributed to the deficiency identified during the survey.