Failure to Enforce COVID-19 Source Control and PPE Requirements During Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement its infection prevention and control program, including required COVID-19 precautions, during an active outbreak that affected all residents. Surveyors observed a sign at the facility entrance stating that staff and visitors were required to wear N95 masks at all times due to a current COVID-19 outbreak. Despite this, four of five night-shift staff members, including two LPNs and two CNAs, were observed inside the facility without any masks. One LPN acknowledged she had a resident on her unit with COVID-19 and confirmed staff were supposed to wear masks at all times. Another CNA stated she was unsure whether staff were required to wear masks at all times and reported working on the LTC unit. A second LPN, who also had a resident with COVID-19 on his unit, stated he did not believe masks worked, was not aware staff were to wear masks, and said he would only wear a regular mask, not an N95, when entering a COVID-positive resident’s room. Another CNA reported being unclear about mask use outside resident rooms and stated that staff had become more relaxed about mask use at night after several residents had COVID-19. Further observations showed improper use of personal protective equipment (PPE) for residents on isolation for COVID-19. A CNA delivering a breakfast tray to a resident on droplet/contact precautions for COVID-19 donned a gown, gloves, and an N95 mask but did not wear eye protection while providing care and handling items in the room. Upon exiting, she removed her gown and gloves, performed hand hygiene, and applied a new N95 mask, later stating she was new and did not know eye protection was required for entering the room of a resident with COVID-19. An RN confirmed that staff were required to wear eye protection when entering such rooms. Record review showed that one resident had tested positive for COVID-19 and was placed on isolation, and another resident later tested positive and was placed on droplet/contact isolation. Facility infection tracking logs documented that 18 residents had tested positive for COVID-19 over a defined period, with all but one remaining in the facility. The facility’s written COVID-19 policy required source control (mask use) for individuals in areas experiencing a SARS-CoV-2 outbreak and specified that staff entering rooms of residents with suspected or confirmed COVID-19 must use an N95 mask, gown, gloves, and eye protection, which was not consistently followed in practice.
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