Failure to Ensure Appropriate PPE Use for Resident on Covid-19 Transmission-Based Precautions
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate use of personal protective equipment (PPE) for a resident on transmission-based precautions (TBP) for Covid-19. During a medication pass on the North hall, an RN entered the room of Resident #30, who verbally reported it was her tenth and final day of isolation for a positive Covid-19 test, wearing only an N-95 particulate respirator and gloves. The RN did not don a gown before entering, despite the facility’s Covid-19 policy requiring a NIOSH-approved N-95 or higher respirator, gown, gloves, and eye protection for healthcare providers entering the room of a patient with suspected or confirmed Covid-19 infection. Observation after the medication pass showed a PPE cart outside the resident’s room and a Droplet Precautions sign that was not prominently displayed, as it was resting diagonally on the handrail, partially obscured by equipment stored in the hallway. Record review showed Resident #30 was admitted on an earlier date with diagnoses including congestive heart failure, chronic kidney disease, hypertensive heart disease, and morbid obesity. Nursing progress notes documented that on a prior date the resident was tested for Covid-19 due to headache, chills without fever, and sore throat, and the test was positive. However, the active physician’s orders did not include a specific order for TBP for Covid-19 or the duration of isolation, only an open-ended order allowing Covid-19 testing as needed. In an interview, the RN confirmed she knew the resident was in isolation for Covid-19, acknowledged that a gown was required PPE for entering the room, and stated she did not wear a gown because none were available in the PPE cart and she did not check other carts. She also acknowledged that the Droplet Precautions sign was not clearly visible or posted on the door where it would be easily seen when the door was closed.
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