F0880

E

Failure to Implement PPE, EBP, and Respiratory Protection Requirements

Olympia, Washington Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper use of personal protective equipment (PPE) and implementation of enhanced barrier precautions (EBP). In one EBP room, a nursing assistant entered to assist a resident with a mechanical lift transfer, donned only gloves, and then exited the room carrying used gloves in the hallway while seeking assistance, before returning to dispose of them and don new gloves. The PPE caddy on that room’s door lacked gowns and disinfectant wipes, and the registered nurse who entered to assist with the transfer also wore only gloves, stating she typically wore gowns only for wound care. Facility policy and state guidance required gowns and gloves for high-contact resident care activities in EBP rooms and disinfection or dedicated use of equipment, but the mechanical lift used for the transfer was not wiped down after use.

Additional observations on two halls showed multiple EBP and quarantine precaution rooms without required PPE stocked in the door caddies and improper handling of soiled linens and trash. Several rooms designated for EBP had no gowns available in the PPE caddies, and rooms on quarantine precautions had no gowns or masks available. Surveyors also observed bagged and unbagged dirty linen and a bag containing a soiled brief placed on the floor in resident doorways. The DON, infection preventionist, and other staff acknowledged that PPE caddies were expected to be stocked and that dirty linen and trash should not be left in doorways, and stated that all staff were responsible for restocking PPE.

The facility also failed to implement a complete respiratory protection program as required by state guidance and its own policy. The Washington State Department of Health guidance and the facility’s Respiratory Protection Program policy required medical evaluation, respirator training, and initial and annual fit testing for N95 respirators before use. The infection preventionist and DON reported there was no current process in place for fit testing staff, that it had likely stopped when the facility changed ownership, and that newly hired staff had not been fit tested. A newly hired nursing assistant reported working about a month, was unfamiliar with fit testing, and stated they used whatever N95s were provided before entering rooms requiring an N95. Review of records for 21 staff hired in the past 90 days showed no documentation that any had been fit tested, and the administrator confirmed they did not have a good plan in place to protect residents from staff who may not have been fit tested for an appropriate N95.