Failure to Implement Covid-19 Transmission-Based Precautions and PPE Practices
Penalty
Summary
Surveyors identified that the facility failed to implement its infection prevention and control program and transmission-based precautions for residents with active Covid-19 infections on one nursing unit. Facility policy required that when airborne precautions are needed and an AIIR is not available, residents be placed in private rooms with doors closed, appropriate signage posted, and staff provided with N95 or higher-level respirators. The Pennsylvania Department of Health Respiratory Virus Outbreak Toolkit further directed masking of HCP, residents, and visitors during respiratory virus outbreaks and specified airborne, contact, and eye protection for SARS-CoV-2, including closed doors, fit-tested N95 respirators, gowns, gloves, and dedicated or disinfected equipment. Facility-provided documentation showed that 18 of 28 residents on the Two South unit were Covid-19 positive, and the facility’s own Covid-19 signage required hand hygiene, use of gown, N95 or PAPR, eye protection, gloves for high-contact care, and keeping doors closed. During observations on the Two South unit, multiple instances of noncompliance with these requirements were found. Several rooms housing residents with active Covid-19 infections had doors open, including rooms with one or both residents Covid-positive. In multiple cases, there was no Covid-19 or transmission-based precautions signage posted on or near the doors, or only Enhanced Barrier Precautions signage was present despite active Covid-19 infection. PPE caddies on some Covid-positive residents’ doors lacked N95 masks or any masks at all, and one room with a Covid-positive resident had no PPE caddy. One room displayed Covid-19 precautions signage even though neither the current resident nor the former roommate was documented as Covid-positive in the medical record. In total, these observations showed failures in door closure, appropriate signage, and availability of required PPE for residents with active Covid-19 infections, affecting 21 of 28 residents on the unit. The Nursing Home Administrator confirmed the facility failed to ensure an environment free from the potential spread of infection for these residents.
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