F0880

D

Failure to Follow COVID-19 Transmission-Based Precautions and Hand Hygiene

Rome, New York Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its infection prevention and control program and follow transmission-based precautions for a resident with confirmed COVID-19. The resident had diagnoses including respiratory failure with hypoxia, wheezing, and COVID-19, was cognitively intact, and dependent on staff for transfers. The resident’s care plan and physician orders documented that the resident was COVID-19 positive and required contact/droplet transmission-based precautions, isolation in a private room, and that all activities, including therapy, dining, and activities, be brought to the room. Facility policy and the enhanced contact-droplet precaution signage required staff to perform hand hygiene when entering and leaving the room, wear an N95 respirator, gown, gloves, and eye protection, keep the door closed when safe, and use disposable or dedicated equipment.

Surveyors observed multiple instances where staff and an outside vendor entered and exited the COVID-19 positive resident’s room without appropriate PPE and without performing hand hygiene. On several occasions, therapy staff, a floor technician, an unidentified outside vendor, CNAs, and the Director of Social Work entered the room without gowns, gloves, N95 respirators, or eye protection, despite enhanced contact-droplet precaution signage posted on the door. Some staff wore only an N95 or only a surgical mask, and others wore no PPE at all. Staff frequently failed to perform hand hygiene upon entering or exiting the room, even after touching the inside of the resident’s door or handling items such as meal trays and a rolling walker. The resident was observed coughing during some of these encounters.

The PPE bin outside the resident’s room was found to be incompletely stocked, containing only vinyl gloves, procedure masks, and isolation gowns, with no N95 respirators, eye protection, or hand sanitizer at one point. Staff interviews revealed that they understood the signage indicated the need for a gown, gloves, N95 mask, and eye protection for COVID-19 precautions, and that these items should be in the PPE bin, but they reported that N95 masks and eye protection were missing and that they sometimes took N95s from other bins or would have to ask where to get more eye protection. The Infection Preventionist/Staff Development Nurse stated they were responsible for signage and PPE bins, that the signage was intended to match the resident’s condition, and that staff were expected to follow the signage and perform hand hygiene after exiting the room. The administrator and medical director both stated that the purpose of the signage was to prevent the spread of infection and that precautions should be followed. The resident reported that staff did not always wear gowns, hardly wore gloves, and were never seen with face shields or goggles, and that therapy staff had provided care without gowns, gloves, masks, or face shields.

Overall, the observations, record review, and interviews showed that the facility did not ensure that staff consistently adhered to its COVID-19 policy, the posted enhanced contact-droplet precautions, and basic hand hygiene practices when caring for a resident with confirmed COVID-19. The failure included incomplete stocking of required PPE in the bin outside the resident’s room, staff entering and exiting the room without required PPE, and repeated failures to perform hand hygiene, despite clear signage and staff acknowledgment of the required precautions.