Failure to Use Required PPE and Isolation Precautions for COVID-19 Positive Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently used appropriate personal protective equipment (PPE) and isolation practices for residents who were COVID-19 positive. Surveyors observed that a receptionist entered the room of a resident on contact/droplet isolation for COVID-19 wearing gloves, gown, and a surgical mask, then exited the room still wearing the PPE and disposed of the gown and gloves in a housekeeping cart in the hallway. Another resident who was COVID-19 positive was in the dialysis room while a dialysis technician provided care wearing only a surgical mask and gloves, without full PPE as required by facility policy. In addition, a COVID-19 positive resident was in the dialysis room without a mask, in the same space as two other residents who were not listed on the COVID isolation list, while dialysis staff wore only partial PPE (surgical masks, with one staff member also wearing a gown and using regular glasses as eye protection). Further observations showed that two residents who were COVID-19 positive did not have contact/droplet isolation signs on their door, only a general PPE instruction sign, and a CNA entered their room wearing only a surgical mask. The CNA stated she did not know whether these residents were on isolation, reporting conflicting information from others. The DON stated that residents who test positive for COVID-19 are to be placed on contact/droplet isolation for 10 days, with a sign on the door and staff required to wear gloves, gown, N95 mask, and face shield, and that COVID-positive residents may leave their rooms for dialysis only if they wear a surgical mask. Facility policies, including the PPE and Source Control Policy, Acute Respiratory Illness Management Policy, and Viral Respiratory Pathogens Toolkit, require appropriate transmission-based precautions, including N95 respirator, eye protection, gown, gloves, room restriction except for medically necessary purposes, and contact/droplet isolation for 10 days for residents with COVID-19. These documented requirements were not followed in the observed instances.
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