Failure to Use Required PPE for COVID-19 Isolation Resident
Penalty
Summary
The deficiency involves a failure to implement appropriate infection prevention and control practices for a resident with confirmed COVID-19. On January 8, 2026, signage posted outside the resident’s room clearly indicated both contact and droplet precautions, instructing that everyone must clean their hands before entering and when leaving the room, and that providers and staff must put on gloves and a gown before room entry. The droplet precaution sign further required that eyes, nose, and mouth be fully covered before entering. The resident’s admission record, dated January 9, 2026, documented a diagnosis of COVID-19. The facility’s written policy on Infection Prevention and Control for COVID-19 Infection, dated June 2023, required all staff to wear fit-tested NIOSH-approved N95 respirators in any indoor space where there are residents in isolation, and specified that eye protection is required when caring for residents in the COVID isolation area. Despite these posted precautions and written policies, on January 8, 2026, at 12:25 p.m., an LVN preparing to check the COVID-positive resident’s blood sugar level was observed donning only a surgical mask, gown, and gloves before entering the room. During a concurrent interview, the LVN acknowledged that the contact and droplet precaution signs were posted to be followed to avoid transmitting bacteria and confirmed that the resident had COVID-19. The LVN further stated she was wearing a surgical mask, gown, and gloves when she entered the room and acknowledged she should have worn an N95 mask and a face shield. In subsequent interviews, the Infection Preventionist Nurse and the Director of Nursing both stated that the LVN should have worn the proper PPE—gown, gloves, N95 respirator, and face shield—before entering the isolation room. CDC Infection Control Guidance for SARS-CoV-2, cited in the report, recommends that healthcare personnel entering the room of a patient with suspected or confirmed SARS-CoV-2 infection use an NIOSH-approved N95 or higher-level respirator, gown, gloves, and eye protection.
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