Failure to Ensure Complete PPE Use for Resident on COVID-19 Isolation
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) protocols for a resident on COVID-19 isolation. On 08/11/2025 at 10:30 AM, a sign on the resident’s door indicated the resident was on isolation and required anyone entering the room to wear an N-95 mask, gloves, isolation gown, and eye protection. At 10:35 AM, a certified nursing assistant entered the resident’s room with linens wearing PPE but without any eye protection, and later exited the room with a clear bag of what appeared to be dirty linens. On 08/12/2025 at 10:58 AM, the infection control nurse confirmed the resident was on isolation for COVID-19 and stated that staff should wear an N-95 mask, gloves, isolation gown, and eye protection when entering the room. The resident’s Order Summary Report dated 08/12/2025 showed an order to maintain strict contact and droplet isolation at all times due to active COVID-19 infection, and the resident’s care plan initiated on 08/05/2025 included an intervention to use appropriate PPE. The facility’s policy on preventing and controlling acute respiratory illness outbreaks, revised 07/16/2025, also specified that required PPE for COVID-19 isolation included eye protection. This deficiency was based on observation, interview, and record review showing that staff did not fully comply with the posted isolation requirements, the resident’s physician orders and care plan, and the facility’s written infection control policy regarding PPE use for COVID-19 isolation.
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