Failure to Implement Proper PPE Protocols During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement proper infection prevention and control practices during a COVID-19 outbreak, specifically regarding the use of personal protective equipment (PPE). Observations revealed that staff and residents were generally wearing surgical masks, but multiple instances occurred where staff did not don the required PPE, such as N95 masks, gowns, gloves, and face shields, when entering rooms of residents with confirmed COVID-19 or when providing care in areas under droplet precautions. In several cases, staff entered rooms of residents in isolation without appropriate PPE, and some staff were unaware of or did not follow posted PPE requirements. For example, a certified nursing assistant (CNA) entered a room shared by a COVID-19 positive resident without donning any PPE, and another CNA provided care to COVID-19 positive residents while only wearing a surgical mask, despite signage indicating the need for an N95 mask and other protective equipment. Interviews with staff indicated confusion and lack of consistent education regarding PPE protocols. Some staff reported not receiving education on proper donning and doffing procedures, while others were unsure about mask requirements or believed that wearing a face shield alone was sufficient. There were also reports of staff being unable to locate N95 masks on the memory care unit (MCU), despite the facility stating that adequate stock was available. This led to staff providing care to COVID-19 positive residents without the recommended respiratory protection. Additionally, staff sometimes failed to review or follow the PPE instructions posted on isolation signage before entering resident rooms. The deficiency affected both residents diagnosed with COVID-19 and those not diagnosed, as improper PPE use increased the potential for transmission. The facility census was 68, with 14 residents identified as having COVID-19 during the outbreak. The facility's own policy required staff to use a NIOSH-approved N95 respirator, gown, gloves, and eye protection when entering the room of a resident with suspected or confirmed COVID-19, but these protocols were not consistently followed as observed and confirmed through staff interviews.