Failure to Ensure Proper PPE Use During COVID-19 Outbreak
Penalty
Summary
During a COVID-19 outbreak, the facility failed to ensure that staff consistently wore appropriate personal protective equipment (PPE) when entering rooms of residents under COVID-19 droplet precautions. Observations revealed that a housekeeping manager entered the room of a resident in COVID-19 isolation wearing only an N95 mask, without a disposable gown or eye protection, despite signage indicating the need for full PPE. The same staff member also entered another room under COVID-19 precautions, donning a gown and gloves but not changing her N95 mask or wearing eye protection. Interviews with housekeeping staff confirmed that they did not change their N95 masks between rooms and were unaware of the requirement to discard masks after exiting rooms under COVID-19 precautions. The infection preventionist confirmed that all staff should be wearing a gown, gloves, N95 mask, and eye protection before entering such rooms and that N95 masks should be changed upon exit. Review of Resident Council meeting minutes indicated that housekeeping staff were not using PPE in COVID-19 rooms before entering other rooms. Facility policy and CDC guidance both require staff to fully cover their eyes, nose, and mouth before room entry and to remove face protection before room exit when under droplet precautions. The deficiency was identified during a complaint survey, and it was noted that the facility had experienced a previous COVID-19 outbreak less than a month prior to the current one. Ten residents were identified as having current COVID-19 infections at the time of the survey.