Improper Hand Hygiene and PPE Use for COVID-19 Isolation Residents
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices related to hand hygiene and proper use of PPE for residents with COVID-19. The facility census was 151 residents, and at least three residents were documented as COVID-19 positive and on contact/droplet isolation with N95 precautions. Isolation tracking records showed that these residents had tested positive for COVID-19 on specific dates and were placed on isolation the same day. Their room doors were posted with signs requiring N95 plus eye protection and contact precautions. Despite these requirements, a CNA was observed going to COVID-19 isolation rooms wearing a surgical mask, then placing an N95 mask over the surgical mask along with other PPE before entering, contrary to the facility’s stated requirement that a fit-tested N95 be worn appropriately without a surgical mask underneath. A PTA was observed exiting a COVID-19 positive resident’s room wearing a surgical mask over an N95 mask, not removing either mask or performing hand hygiene upon leaving the room, and then proceeding directly to another COVID-19 positive resident’s room wearing the same masks. The PTA stated he performs in-room therapy with COVID-19 positive residents and relies on door signs to identify isolation status, and also stated he believed he could go to multiple COVID-19 rooms wearing the same N95 mask. The Infection Prevention Nurse and Director of Rehab both stated that residents with COVID-19 are on contact/droplet isolation requiring gown, gloves, eye protection, and an N95 mask, and that all PPE, including the N95, must be changed and hand hygiene performed between residents. The Regional Nurse reported that staff are educated on donning and doffing PPE using the isolation poster. Facility policies and posted signage required hand hygiene before entering and after leaving rooms and removal of the N95 after exiting, which was not followed in the observed instances.
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