Failure to Follow Special Droplet Contact Precautions for Covid-19 Positive Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to failure to follow special droplet contact precautions for a resident with confirmed Covid-19. Facility policy dated 10/24/24 required implementation of special droplet contact precautions for newly identified Covid-19 cases, and the resident’s positive Covid-19 test on 3/14/26 resulted in placement on these precautions with signage posted outside the room. The posted signage dated 11/22 instructed staff to perform hand hygiene before entering and to wear a gown, N95 mask, eye protection, and gloves upon entry. Despite this, on 3/16/26 at 12:52 PM, two nursing assistants entered the resident’s room wearing only surgical masks, without performing hand hygiene before entry and without donning a gown, gloves, eye protection, or an N95 mask, while physically assisting the resident to sit on the side of the bed and setting up the lunch tray. They washed their hands with soap and water only after exiting the room and later acknowledged they should have worn the required PPE but did not and could not explain why. On 3/17/26 at 8:55 AM, another nursing assistant was observed inside the same resident’s room wearing a gown, gloves, eye protection, and a surgical mask instead of the required N95 mask while physically repositioning the resident in bed. This staff member removed PPE and washed hands with soap and water after exiting the room but reported she had been in a hurry and did not put on an N95 mask. The DON stated that the first two nursing assistants reported they had not read the special droplet contact precaution signage posted at the resident’s door, and that the third nursing assistant had received education on special droplet contact precautions but still did not follow protocol, stating she put on the wrong mask outside the room. The Administrator confirmed staff should have followed the posted special droplet contact precaution signage and could not explain why they did not.
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