Failure to Use Appropriate PPE for Residents on Droplet Precautions
Penalty
Summary
The deficiency involves staff failure to follow the facility’s infection prevention and control program and Transmission-Based Precautions for residents on droplet precautions for COVID-19. One resident with severe vascular dementia and a recent positive COVID-19 test had a droplet precaution sign posted on the room door. Despite this, the Social Services Director entered the resident’s room wearing only a surgical mask and did not perform hand hygiene upon entry. In a subsequent interview, the Social Services Director acknowledged awareness of the droplet precautions and stated they should have slowed down and read the precaution signage on the door. Another resident with COPD, moderate cognitive impairment, and a recent positive COVID-19 test following a hospital stay also had a droplet precaution sign posted on the room door. The sign instructed that everyone must clean their hands before entering and leaving the room and ensure eyes, nose, and mouth were fully covered before entry. A housekeeper was observed in this resident’s room wearing a gown, gloves, surgical mask, and face shield. When questioned, the housekeeper stated they believed they were supposed to wear an N95 mask for this COVID-19 positive resident, acknowledged they were not wearing an N95 mask, and could not explain why. The DON later reported that the expectation for contact with COVID-19 positive residents was to wear a gown, gloves, N95 mask, and face shield.
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