F0880

F

Failure to Implement PPE, Hand Hygiene, and Isolation Practices During COVID-19 Outbreak

Texarkana, Texas Survey Completed on 02-26-2026

Penalty

Fine: $31,440

Summary

The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program during a COVID-19 outbreak, including failure to ensure staff consistently followed facility policies for PPE use, hand hygiene, and isolation practices. Surveyors observed multiple instances where staff entered COVID-positive residents’ rooms or provided services to them without the required PPE. A certified nursing assistant (CNA) passed meal trays on a COVID-positive hall without wearing a gown, gloves, N95 mask, or face shield/goggles, moving directly between COVID-positive and COVID-negative rooms. The Dietary Manager (DM) entered a room posted with droplet precautions multiple times wearing only a KN95 mask, delivering and removing meal trays and cups for COVID-positive residents, and did not consistently perform hand hygiene upon exiting the room.

The report details that an Admission Coordinator (AC) delivered a meal tray to a COVID-positive resident while wearing only a surgical mask and no gown, gloves, or eye protection, despite droplet precaution signage on the door. After exiting the room, the AC handled cups and used the hallway ice chest and scoop without first sanitizing her hands, then returned the cups to nursing staff. Surveyors also observed that PPE supply carts for several COVID-positive residents lacked required items such as N95 masks, gloves, and face shields/goggles. During the same outbreak period, an LVN entered a COVID-positive resident’s room wearing only a KN95 mask and stated that a KN95 mask was appropriate and that face shields or goggles were optional, and later was observed in another COVID-positive resident’s room wearing only a surgical mask with no gown, gloves, or eye protection while assisting the resident.

Additional deficiencies included improper glove use and hand hygiene during clinical care. An LVN checked a resident’s blood sugar and then administered enteral tube medications without changing gloves or performing hand hygiene in between tasks. Interviews with staff, including LVNs, the AC, the DM, the Infection Preventionist (ADON), the DON, and the Regional Administrator, confirmed inconsistent understanding and implementation of PPE requirements for COVID-positive rooms, confusion about the difference between N95 and KN95 masks, and uncertainty about who was responsible for stocking PPE carts. Facility policies reviewed by surveyors specified that N95 masks with goggles or face shields, gowns, and gloves were required for COVID isolation rooms, and that hand hygiene was required after removing gloves, after handling soiled items, and before handling food or medications. Despite these policies, observations and interviews showed that staff did not consistently adhere to these infection control requirements during the COVID-19 outbreak.

The report also notes that several residents involved had significant medical conditions and were on isolation precautions for active infectious disease, including COVID-19. These residents included individuals with chronic obstructive pulmonary disease, Non-Hodgkin lymphoma, laryngeal cancer, cerebral palsy, prior COVID-19, neutropenia, fractures, and stroke-related hemiplegia/hemiparesis. Many had severe cognitive impairment as indicated by low BIMS scores, and some required extensive assistance with activities of daily living or had feeding tubes. Facility records, including care plans, MDS assessments, and physician orders, documented that these residents were COVID-positive and on droplet/respiratory isolation, with interventions specifying use of PPE and infection control practices. However, surveyor observations and staff interviews demonstrated that these ordered precautions and facility policies were not consistently implemented in practice.