Failure to Follow Airborne/Contact/Droplet Precaution Protocols During Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to implement required infection control protocols for residents on Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP), specifically airborne/contact/droplet precautions. During lunch delivery, an activity assistant entered a resident’s room that had signage for airborne/contact/droplet precautions wearing only a gown and a surgical mask, without donning an N95 mask, eye protection, or gloves as required by the posted instructions. The signage indicated that before entering the room, staff should cleanse their hands and don a gown, N95 mask, eye protection, and gloves. Upon exiting this room, the activity assistant did not perform hand hygiene and kept the same surgical mask on, then immediately handled meal trays and fluids from the carts. The same activity assistant then entered another resident’s room, also posted for airborne/contact/droplet precautions, without donning any eye protection, gown, or N95 mask, and again did not perform hand hygiene upon exiting while continuing to use the same surgical mask. Later, after being instructed by another staff member, the assistant donned a gown before entering a third room with airborne/contact/droplet precautions signage but still did not wear an N95 mask or eye protection. After leaving this third room, the assistant performed hand hygiene. In an interview, the activity assistant confirmed that eye protection had not been worn in any of the identified COVID rooms, stated that an N95 mask was not used because a surgical mask was believed to be sufficient, and acknowledged not wearing a gown in one room and not performing hand hygiene when exiting two of the rooms.
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