Failure to Enforce PPE and Infection Control Protocols During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement its Infection Prevention and Control plan as outlined in its policy and procedures, specifically regarding the use of personal protective equipment (PPE) and adherence to standard and transmission-based precautions. Observations revealed that a resident admitted with COVID-19 infection required various levels of assistance from staff, yet staff did not consistently follow proper PPE protocols. For example, a Licensed Vocational Nurse was observed with her N-95 mask positioned below her chin, and a Certified Nurse Assistant (CNA) entered the COVID-19 positive resident's room without wearing a gown and gloves, later admitting she was unaware that the N-95 mask was for single use. The CNA also donned PPE incorrectly by putting on gloves before the gown, contrary to recommended procedures. Additional observations included another CNA not wearing a mask while inside the facility during a COVID-19 outbreak and a pharmacy delivery person entering the building without a mask or performing hand hygiene, with no infection control supplies available at the entrance. The Infection Prevention Nurse confirmed that all staff should wear N-95 masks upon entering the building and use appropriate PPE when indicated by signage. The facility's policy required standard and transmission-based precautions, hand hygiene, and proper selection and use of PPE, but these were not consistently followed as observed.