Improper N95 Respirator Use Contrary to Fit Test Results During COVID-19 Outbreak
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper use of N95 respirators by staff during a period when the facility had active COVID-19 cases. A sign at the entrance indicated there were current COVID-19 cases and requested visitors to wear masks. The RN stated that, due to positive COVID-19 cases in the facility, staff were required to wear N95 masks throughout their shifts and that staff were fit tested to ensure they wore the correct N95 model to decrease the spread of COVID-19. The Infection Preventionist (IP) confirmed there were eight COVID-19 positive residents in the facility and that staff were required to wear N95 masks while in the building. During observations and interviews, surveyors found that two staff members were not wearing the N95 respirator models for which they had been fit tested. A CNA was observed wearing a solid white circular N95 mask and stated she had been fit tested approximately six months earlier and was wearing the mask she believed was indicated. However, review of her Respirator Fit Test Record dated March 26, 2025, showed she was fit tested for a 3M N95 (white duckbill-shaped mask), not the solid white circular model she was wearing. Similarly, an LVN was observed wearing a solid white circular N95 mask and reported she had been fit tested about one month earlier and was wearing the mask she believed was indicated. Her Respirator Fit Test Record dated November 24, 2025, showed she was fit tested for a Medline N95 (green and white striped mask), not the solid white circular model. The IP verified these discrepancies and stated that wearing the wrong N95 mask does not protect staff from infectious disease and that they then pose a risk of spreading infectious disease to others. Facility policies on fit testing and COVID-19 PPE requirements specified that employees must be fit tested using the same size, make, model, and style of respirator they will wear and that staff are required to wear N95 respirators and be fit tested annually.
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