ATHENS, PA - Federal inspectors found serious infection control violations at Athens Health and Rehabilitation Center during an August 1, 2024 complaint investigation, citing the facility for improper COVID-19 safety protocols that potentially exposed staff and other residents to infection.
Improper Masks Used During COVID Care
The most concerning violation involved staff using surgical masks instead of required N95 respirators when caring for COVID-positive residents. During the inspection, surveyors observed a nurse aide exiting a COVID patient's room wearing only a blue surgical mask after performing close-contact care.
The aide had just finished emptying the urine collection bag for a resident's indwelling catheter, a procedure requiring her to be within a few feet of the infected patient. When questioned, the aide stated she "just grabbed the one on top" from the personal protective equipment (PPE) organizer and noted that the room signage "doesn't say which mask is required."
This violation is medically significant because surgical masks provide substantially less protection than N95 respirators. While surgical masks may block large droplets, N95 respirators filter at least 95% of airborne particles, including the smaller aerosols that can carry COVID-19. Healthcare workers caring for COVID patients face increased infection risk when proper respiratory protection is not used.
Inadequate Safety Signage
Inspectors found the facility was using improvised signage that failed to communicate proper safety requirements. Both COVID-positive residents had contact precaution signs on their doors with the word "Contact" crossed out and "Droplet" handwritten in black marker. These modified signs did not include requirements for eye protection, which is mandatory for droplet precautions according to CDC guidelines.
The CDC's transmission-based precautions specifically state that droplet precautions require full coverage of eyes, nose, and mouth before entering patient rooms. Eye protection prevents infection through mucous membranes when respiratory droplets are generated by patients coughing, sneezing, or talking.
Staff Confusion About Requirements
The inspection revealed systemic confusion about infection control protocols. The nurse aide questioned why surgical masks were available in the PPE organizer if they weren't appropriate for use. A registered nurse confirmed during interviews that the facility's signage did not include necessary measures for droplet precautions and acknowledged they were using contact precaution signs with handwritten modifications.
This confusion creates dangerous situations where healthcare workers may unknowingly use inadequate protection. Proper infection control requires clear, standardized signage that unambiguously communicates required PPE for each type of isolation.
Medical Risks and Standards
COVID-19 spreads primarily through respiratory droplets and aerosols produced when infected individuals breathe, speak, cough, or sneeze. In healthcare settings, close contact with infected patients significantly increases transmission risk, particularly during procedures like catheter care that require proximity to the patient.
Healthcare facilities are required to implement transmission-based precautions that go beyond standard precautions when caring for patients with infectious diseases. For COVID-19, this includes using N95 or higher-grade respirators, eye protection, gloves, and gowns during patient care activities.
The Athens facility had N95 masks available but failed to ensure staff understood when and how to use them properly. This represents both a training failure and a system failure in infection control protocols.
Previous Violations
The inspection report notes this was a previously cited infection control deficiency from June 14, 2024, indicating ongoing challenges with infection prevention at the facility. Repeat violations suggest systematic problems that require comprehensive corrective action plans.
Regulatory Context
The violations fall under federal infection control standards (F880) which require nursing homes to establish and maintain infection prevention and control programs. Pennsylvania state regulations also mandate proper nursing services and management oversight of infection control practices.
Federal and state regulators take infection control violations seriously because they can lead to facility-wide outbreaks that endanger vulnerable nursing home populations. COVID-19 has disproportionately affected nursing home residents, making proper infection control protocols critically important for resident safety.
The Athens facility must submit a plan of correction detailing how they will address these violations and prevent future occurrences. This typically includes staff retraining, updated policies and procedures, and enhanced monitoring systems to ensure compliance with infection control standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Athens Health and Rehabilitation Center from 2024-08-01 including all violations, facility responses, and corrective action plans.
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