COVID-19 Prevention: Masking for Nursing and Residential Care
This resource is for employers who provide care for the elderly or others in long-term care facilities such as skilled nursing facilities, adult family homes, and assisted living facilities.
When Masks are Required
Hazard Assessment: Masking is generally required for healthcare settings by state order. In addition, selection of specific types of masks for workers depends on the work task or activity and level of risk as determined by a COVID-19 hazard assessment.
Hazard assessments take into account how close workers get to others known or not known to have COVID-19, how much time they spend during those interactions, the current COVID-19 community transmission level, whether activities generate potentially infectious aerosols or secretions, whether effective ventilation is used, and other aspects of the work setting that could increase exposure risk, such as the occurrence of COVID-19 outbreaks at the facility or within the community.
Respirators: N95s, P100s, or other respirators are required:
- Anytime workers directly interact with, or enter a room occupied by someone known or suspected to have COVID-19.
- When present during procedures such as use of CPAP, BiPAP, or induction of sputum: or when the COVID-19 community transmission level is high.
- At other times based on a COVID-19 hazard assessment. As part of your assessment, consider universal N95 use during periods of high community transmission and also when COVID-19 cases (resident or worker) have been identified.
Facemasks: Medical procedure or surgical masks (with or without attached face shield for eye protection) are appropriate when risk for COVID-19 is elevated but isn’t high enough to warrant respirator use. For most healthcare settings, facemasks are the minimum when masks are required.
How Respirators and Facemasks Differ
Respirators: N95s and other respirators protect the wearer from inhaling potentially infectious particles from the air. They can also be used as “source control” to prevent an infected person from spreading exhaled particles into the air.
Respirators referred to as tight-fitting rely on an air-tight seal to work effectively; these include N95s, P100s, and styles with rubber-like (elastomeric) face pieces. Hooded Powered Air-Purifying Respirators (PAPRs) are loose-fitting and so can be worn with facial hair.
Tight-fitting respirators, when required, must not be used until the worker passes an initial fit test for the specific model and size of respirator used. Stubble and other facial hair in the mask-to-face seal area can compromise the air-tight seal and is therefore prohibited.
When required, respirators used for COVID-19 prevention must have a “TC” approval number from the National Institute of Occupational Safety and Health (NIOSH) printed on the mask or in product packaging. Some N95s are also approved by the Food and Drug Administration (FDA) as surgical masks.
Respirators with exhalation valves may not be used in settings where a sterile field must be maintained - elastomeric models without exhalation valves are acceptable, as are “surgical” N95s with additional approval by the FDA.
Facemasks: These masks provide some protection from COVID-19 (as PPE or source control); however, they are less protective than respirators for a couple of reasons:
- They are loose fitting and do not provide air-tight seal to the wearer. They will not pass a fit test.
- The filter material doesn’t meet NIOSH’s minimum efficiency of 95%.
Required vs. Voluntary Use of Respirators
When respirators aren’t required, workers may request to use a respirator or other mask voluntarily.
Before a worker uses a respirator voluntarily, the employer must provide them information in WAC 296-842-11005 Table 2. As a best practice, employers can also encourage workers to review, What Workers Should Know About Voluntary Use of Masks.
Respiratory Protection Program
If requiring respirators at work, employers must:
- Develop a written respiratory protection program and designate a program administrator. Find a sample program to customize here.
- Select and provide appropriate respirators at no cost to employees.
- Ensure workers are medically cleared for use, provided an initial fit-test, and trained on proper respirator use and maintenance.
- Instruct workers using N95s and other tight-fitting respirators to remain clean-shaven where the respirator contacts the face to ensure an air-tight seal.
- Follow other requirements outlined in the respirator rule, WAC 296–842, to ensure ongoing and reliable protection.
Employees required to use respirators solely as source control (to protect others working around them) may be covered under the employer’s voluntary use respirator program. See When Masks are Used Voluntarily – Employer Responsibilities to learn more about voluntary use program requirements.
Other COVID-19 Precautions
In addition to masking, the following safety precautions can help reduce risk for COVID-19.
- Consider limiting the number of workers providing direct care to patients/clients. For example, group COVID-19 clients near each other and dedicate staff to care for them.
- Use curtains or other barriers to protect from droplets during face-to-face interactions.
- Improve ventilation by increasing the amount of fresh or filtered air. See the fact sheet, Ventilation and Air Quality for Reducing Transmission of Airborne Illnesses.
- Use all required PPE (such as eye protection, gloves, and gowns).
- Continue good handwashing and surface disinfection practices. A list of disinfectants that meet Environmental Protection Agency criteria for use against the coronavirus is available.
- Ensure visitors are aware that masking is required by state order 20-3.10.
Hazard Assessment, Training, and Fit Testing Resources
- L&I's COVID-19 safety topic page
- How to Assess COVID-19 Hazards at Work
- Instructional video demonstrating how to conduct a respirator fit test for N95s
- PowerPoint training covering the basics of N95s and other masks
- What employers need to do when an employee gets COVID-19
- Free fit-testing services, webinars, and other resources for qualified businesses. Visit the Washington State Department of Health Fit Testing Project
For a free safety and health consultation go to www.Lni.wa.gov/SafetyConsultants or call 1-800-423-7233 or visit a local L&I office.