Failure to Implement Effective Infection Control and COVID-19 Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, resulting in multiple lapses in COVID-19 management for 18 out of 32 residents reviewed. The facility did not conduct proper contact tracing or identify all individuals exposed to COVID-19, nor did it initiate exposure testing or implement Transmission Based Precautions (TBPs) for those exposed. In several cases, residents who were exposed to COVID-19 positive individuals were not monitored, tested, or placed on appropriate precautions, and documentation of testing and monitoring was inconsistent or absent. For example, after a resident tested positive for COVID-19, their roommate was not identified as exposed, nor were they placed on precautions or scheduled for follow-up testing. Other residents who were exposed to COVID-19 positive staff were only monitored for symptoms, without TBPs or exposure testing, and staff interviews confirmed that asymptomatic residents were not routinely tested. The facility also failed to implement universal source control and enforce the use of appropriate personal protective equipment (PPE) for both staff and residents. Observations revealed that staff did not consistently wear N95 respirators or eye protection as required, and some staff wore non-approved masks such as KN95s. Fit testing and training for N95 use were not consistently verified, and staff were observed entering and exiting COVID-19 units without donning or doffing PPE as posted. Additionally, signage and instructions for PPE use were either missing or not followed, and staff entered COVID-19 units through unmarked doors without being alerted to the need for PPE. In the therapy gym, concurrent therapy sessions were conducted with multiple residents and staff present, some of whom were not masked or were coughing, increasing the risk of transmission. Residents on Enhanced Barrier Precautions did not have PPE readily available for staff, and staff failed to use gloves and gowns during high-contact activities. Several residents who tested positive for COVID-19 were observed outside their rooms or in common areas without masks, and staff did not consistently follow posted precautions. These failures were documented through direct observation, interviews, and record reviews, demonstrating a systemic breakdown in infection control practices.