Failure to Enforce Staff Masking and Active Visitor Screening During COVID-19 Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to fully implement its infection prevention and control program during a COVID-19 outbreak, specifically related to staff masking and visitor screening. On one observation date, a maintenance worker was seen walking through the facility without a face mask and acknowledged he was aware of the COVID outbreak and did not have a mask. Around the same time, a laundry aide was observed exiting a stairwell and walking to the time clock without a face mask or name badge; she stated she was not wearing a mask and had received the facility’s COVID education training. The maintenance supervisor stated staff should always wear a mask upon entry and exit during a COVID outbreak, but reported that the maintenance worker and laundry aide were not listed on the general in-service record, and he did not keep minutes of his staff meetings. The infection preventionist’s review of COVID isolation and PPE in-service training sheets showed that CDC and California Department of Public Health (CDPH) COVID-19 guidance had been reviewed with CNAs, RNs, and all departments, but the in-service report did not include names or signatures for laundry and housekeeping staff. The infection preventionist stated that staff not receiving in-service training and not wearing a face mask could cause transmission of the COVID outbreak to residents, staff, and visitors. A second deficiency was identified regarding visitor screening and source control during the same COVID outbreak. On two separate observations, the receptionist area at the entrance was unmanned, with boxes of N95 masks and signs instructing visitors to wear a mask due to the outbreak, but no staff were present to perform visitor screening or temperature monitoring. A visitor was observed entering the facility without putting on a mask or signing the visitor logbook, which contained symptom-related questions. The DON stated that the receptionist and several other staff were out due to COVID, that the receptionist area was unmanned, and that visitors were expected to self-sign in, with no one monitoring the self-sign-in process. Review of CDPH Healthcare-Associated Infections Program guidance for 2024–2025 indicated that during periods of increased community transmission of respiratory viruses and in the event of an outbreak, facilities should implement active screening of visitors for signs and symptoms of respiratory virus infections.
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