F0880

D

Failure to Follow COVID-19 Symptom Testing Protocols and PPE Requirements During Outbreak

Mount Pleasant, Pennsylvania Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow CDC-based infection prevention and control guidelines for early detection, testing, and appropriate PPE use during a COVID-19 outbreak. CDC guidance cited in the report emphasizes routine assessment of all residents for COVID-19 symptoms, prompt testing of anyone with even mild symptoms regardless of vaccination status, and use of N95 respirators, gowns, gloves, and eye protection for all HCP entering rooms of residents with suspected or confirmed COVID-19. The facility had 18 residents develop COVID-19 between late December and early January and 11 active cases at the time of the on-site visit, yet staff practices and testing decisions did not consistently align with these guidelines.

For Resident 4, who had a standing physician order allowing COVID-19 testing as needed per protocol, nursing documentation on one date showed a low-grade fever, body aches, chills, shortness of breath, and a dry cough. Despite these symptoms and the standing order, no COVID-19 test was performed at that time. Later in the month, the resident again exhibited symptoms including headache, fatigue, malaise, cough, and a temperature of 100.4°F, at which point a rapid COVID-19 test was performed and was positive, and isolation/combined droplet/contact precautions were ordered. During interview, the IP and DON stated that symptomatic residents would typically be tested, but that this depended on the practitioner, and the DON confirmed that Resident 4 had standing orders for testing that were not used on the earlier symptomatic date.

For Resident 10, who also had a standing order permitting COVID-19 testing as needed, multiple nursing notes over several days documented cough, congestion, malaise, pale skin, and remaining in bed due to not feeling well, while the facility already had active COVID-19 cases. COVID-19 testing was not obtained until several days after the onset of these symptoms, when the CRNP was notified and ordered a rapid COVID-19 swab that resulted positive, and isolation/combined droplet/contact precautions were then ordered. For Resident 11, a nursing note documented that the resident did not feel well, had a moist productive cough, body aches, malaise, and expiratory wheezing; a rapid COVID-19 swab was ordered and was positive, and transmission-based precautions were ordered. Additionally, an observation showed a laundry aide entering the shared COVID-19-positive room of Residents 10 and 11 wearing only a surgical mask, despite droplet precaution signage and an isolation station with N95 masks, gowns, gloves, and eye protection at the door. The laundry aide acknowledged he should have gowned and possibly worn an N95 and confirmed he did not initially realize the PPE was available, while the IP confirmed that all staff entering COVID-19-positive rooms were required to don gloves, an N95, eye protection, and a gown.