Failure to Implement Enhanced Droplet Precautions and PPE for COVID-19
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control practices, including hand hygiene, transmission-based precautions, and use of PPE, for a resident on Enhanced Droplet Precautions for COVID-19. Surveyors observed signage at the public entrance indicating active COVID-19 cases in the building and a sign on the resident’s door requiring an N95 mask, gown, gloves, and eye protection. A PPE cart outside the room contained eye protection, masks, and gloves, but no isolation gowns, and no PPE was observed inside the room or in the trash receptacle. On multiple occasions, staff entered and exited the resident’s room wearing only a face mask, without gowns, gloves, or eye protection, and no hand hygiene was observed before or after room entry. One staff member entered the resident’s room to deliver medications while the resident was in the shower, then immediately went into another resident’s room wearing the same mask and without performing hand hygiene. The resident reported being in isolation for 14 days after testing positive for COVID-19 and stated that staff did not always wear gowns or all the required isolation gear, suggesting inconsistent adherence to the posted precautions. Staff interviews confirmed lapses in practice and knowledge: one staff member acknowledged that PPE should have been worn but was not, another stated it had been quite some time since they had training, and a contracted staff member reported not receiving updated training on transmission-based precautions from either the agency since 2023 or the facility. This contracted staff member also had an incorrect understanding of when eye protection was required for Enhanced Droplet Precautions and did not understand when Enhanced Barrier Precautions would be used. The facility was unable to provide requested documentation of staff education on Enhanced Droplet and Enhanced Barrier Precautions by the end of the survey, despite having a written policy dated 9/13/25 requiring N95 or higher respirator, gown, gloves, and eye protection for conditions such as COVID-19, and CDC guidance specifying hand hygiene and full PPE for Enhanced Droplet Precautions.
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