Failure to Implement COVID-19 Precautions and PPE Use
Penalty
Summary
The facility failed to implement appropriate COVID-19 infection prevention and control precautions for residents who tested positive during an outbreak. Medical record review identified 24 residents who were COVID-19 positive at the start of the outbreak. Multiple direct observations revealed that staff, including registered nurses, licensed practical nurses, and certified nursing assistants, entered rooms of COVID-19 positive residents without donning the required personal protective equipment (PPE) such as N-95 respirators, gowns, gloves, and face shields. Instead, staff were observed wearing only surgical masks while performing tasks such as administering medications and delivering meal trays. Interviews with the involved staff confirmed their lack of compliance with PPE protocols, with some staff acknowledging they forgot to wear the appropriate equipment. Facility policy and posted signage required the use of full PPE for contact and droplet precautions in rooms of COVID-19 positive residents. The failure to follow these protocols was observed on several occasions and verified through staff interviews, affecting the infection control measures for all 58 residents in the facility.