Failure to Follow Infection Control Protocols During Outbreak and Inadequate Equipment Maintenance
Penalty
Summary
Staff failed to adhere to the facility's infection prevention and control policies during a COVID-19 outbreak. Despite the facility's policy requiring all staff to wear source control (surgical mask or N-95 respirator) during outbreak status, multiple staff members, including nurse techs, an LPN, and an environmental services tech, were observed in various hallways and resident rooms without masks. This occurred even in areas with confirmed COVID-19 positive residents and in rooms with droplet precautions signage. Interviews with staff and the administrator confirmed that guidance had been provided to wear masks, but compliance was not maintained. The facility also failed to implement Enhanced Barrier Precautions (EBP) for a resident with a chronic wound, as required by policy. The resident had an unstageable pressure ulcer and required EBP, including the use of gowns and gloves during high-contact care and appropriate signage outside the room. Observations revealed that no EBP signage was posted, gowns were not available, and staff, including the wound nurse, did not don gowns during wound care. Staff were observed performing wound care without proper PPE and then moving throughout the facility, and interviews confirmed that EBP was not in place as required. Additionally, six recliners in a commons area had vinyl coverings that were peeling away from the armrests and seats, making them unable to be fully cleaned. The Environmental Services Director confirmed that the damaged chairs could not be properly sanitized, increasing the potential for cross contamination in the shared area.