Failure to Follow COVID-19 Isolation Protocols
Penalty
Summary
The facility failed to implement its infection control program to prevent the spread of COVID-19 when two Certified Nurse Assistants (CNAs) did not adhere to established protocols for droplet isolation precautions. In one instance, a CNA entered a COVID-19 isolation room to serve a lunch tray without wearing the required eye protection, despite clear signage and the availability of face shields at the door. The CNA acknowledged awareness of the requirement but stated she forgot to put on the eye protection. The Director of Nursing (DON) and Infection Prevention Nurse (IPN) confirmed that this action was not in accordance with the facility's Respiratory Virus Prevention & Control Plan, which mandates the use of appropriate personal protective equipment (PPE) including eye protection for staff entering isolation rooms. In a separate incident, another CNA exited a COVID-19 isolation room without closing the door behind her, contrary to facility practice and CDC guidance, which require doors to remain closed to limit the spread of respiratory droplets. The CNA admitted she was aware of the requirement but forgot to close the door. The DON confirmed that while there was no written policy specifically about door closure, it was the facility's practice to keep doors closed for residents under droplet isolation. Review of the facility's policies and CDC guidance further supported the expectation that doors should be kept closed for residents with suspected or confirmed COVID-19. These lapses in protocol were observed during the care of residents under droplet isolation precautions.