Failure in Infection Control Protocols
Penalty
Summary
The facility failed to implement adequate COVID-19 and Influenza monitoring, tracking, and testing in accordance with state and federal guidance, affecting 95-101 residents over a period from late November to mid-January. The facility did not adhere to the required protocols for identifying and managing outbreaks, which included failing to conduct timely testing and monitoring of residents and staff for symptoms of these illnesses. This oversight placed all residents in an Immediate Jeopardy situation. Several residents with symptoms consistent with COVID-19 and Influenza were not properly monitored or tested. For instance, a resident who tested positive for COVID-19 at the hospital was not accurately tracked by the facility, and another resident with a cough was not tested for Influenza despite exhibiting symptoms. Additionally, the facility's COVID tracking log was inaccurate, and there was a failure to test residents on the required days following exposure. The facility also failed to follow return-to-work guidelines for staff who tested positive for COVID-19. An Infection Preventionist returned to work before the recommended period had elapsed, contrary to the guidelines. Furthermore, the facility did not update signage to reflect the ongoing Influenza outbreak, which was confirmed by multiple positive cases among residents and staff. These lapses in protocol and communication contributed to the Immediate Jeopardy situation.
Plan Of Correction
1. Infection Control Policies and Procedures were updated and are current as of 16JAN2025 to include guidance related to COVID-19 and Flu from CMS, the Center for Disease Control and PA DOH. 2. To prevent reoccurrence, Infection Preventionist, DON/Designee will conduct routine walking rounds to monitor proper use of personal protective equipment and to ensure infection control procedures are followed in accordance with PA DOH COVID 19 Infection Control and Outbreak Response Toolkit for Long Term Care. 3. The DON/designee will complete education by 11FEB2025 with all staff to include use of personal protective equipment (PPE), prevention, identification, and monitoring of signs and symptoms of COVID-19 and Flu in accordance with PA DOH COVID 19 Infection Control and Outbreak Response Toolkit for Long Term Care. 4. The DON/designee will complete education by 11FEB2025 with all staff to include proper co-horting protocol, proper social distancing and how to communicate with residents to encourage compliance with guidance related to COVID-19 and Flu PA DOH Infection Control and Outbreak Response Toolkit for Long Term Care. 5. The DON/designee will complete education by 11FEB2025 with all clinical staff on storage and transportation of soiled linens, sharps containers, and biohazard material per facility policy. 6. The DON/Designee will complete education by 11FEB2025 with all clinical staff on proper handwashing procedure, including the use of alcohol-based sanitizers. 7. The DON/Designee will ensure education by 11FEB2025 with all staff on return-to-work guidelines related to COVID-19 and Flu PA DOH Infection Control and Outbreak Response Toolkit for Long Term Care. 8. DON/Designee will conduct audits to monitor for completion of Day 1 testing for positive COVID results, daily x 5 days for 14 days, then weekly for 4 weeks then monthly x2. 9. To prevent reoccurrence, DON/Designee will conduct ongoing monitoring for COVID positive staff and monitor return to work status, once a week x2 weeks, monthly x 2 with outbreak occurrence in accordance with PA DOH COVID 19 Infection Control and Outbreak Response Toolkit for Long Term Care by 1/16/25. 10. To prevent reoccurrence, DON/Designee will conduct ongoing monitoring for Influenza signs and symptoms and testing, weekly with occurrence in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care by 1/16/25. 11. The Infection Preventionist will be assigned CDC Infection Preventionist training in CDC-Train to be completed by 11FEB2025 to enhance awareness and compliance with infection control and prevention protocols. Root Cause(s): 1. Knowledge deficit for Infection Prevention Nurse and DON. 2. Performance concerns regarding adhering to guidelines after Education. 3. Facility need for evaluation of new Director of Nursing and Assistant Director of Nursing /Infection Prevention nurse. Facility removed the Director of Nursing and Infection Prevention Nurse from roles, terminated, and replaced with Interim DON and Interim ADON. The Interim ADON will absorb the role of the Infection Prevention Nurse and complete the CDC Infection Preventionist Training in CDC-Train. The facility immediately implemented monitoring, testing and tracking for signs and symptoms of influenza and COVID-19 like symptoms among residents and staff in accordance with the PA DOH COVID-19 Infection Control and Outbreak Response Tool-Kit for Long-Term Care. Effective 1/15/25, facility will ensure that COVID testing occurs on Day 1 following a positive result in accordance with PA DOH COVID 19 Infection Control Outbreak Response Toolkit for Long Term Care. -IP/Designees will conduct house audit of all COVID testing to ensure Day 1 testing complete upon positive result by EOD 1/16/25. -Regional Director of Clinical Services will conduct in-service regarding Infection Control and Outbreak Response testing procedures to facility Infection Preventionist and Director of Nursing by 1/16/25. -IP/Designee will conduct education to all staff regarding Infection Control and Outbreak Response testing procedures at their start of beginning 1/15/2025 and before next shift by EOD 1/16/25. -To prevent reoccurrence, DON/Designee will conduct audits to monitor for completion of Day 1 testing for positive COVID results, daily x5 days for 14 days, then weekly for 4 weeks then monthly x2. Negative findings will be addressed. Policies and Procedures to be reviewed and updated as needed. PA DOH Influenza Outbreak Response Toolkit for Long Term Care beginning 1/15/25 and before next shift by EOD 1/16/25. -To prevent reoccurrence, DON/Designee will conduct ongoing monitoring for Influenza signs and symptoms, weekly with occurrence in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care by 1/16/2025. Negative findings will be addressed. Policies and Procedures to be reviewed and updated as needed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Removal Plan
- Facility initiated monitoring signs and symptoms for residents with COVID.
- IP/Designee will conduct house audit of residents with signs and symptoms of COVID.
- Regional Director of Clinical Services will conduct in-service regarding Infection Control and Outbreak Response to facility Infection Preventionist and Director of Nursing.
- IP/Designee will conduct education to all staff regarding infection control measures and monitoring at their start of shift.
- DON/Designee will conduct audits to monitor for resident's signs and symptoms for COVID, daily for 14 days, then weekly for 4 weeks then monthly.
- Negative findings will be addressed. Policies and Procedures to be reviewed and updated as needed. Ad hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
- Facility will ensure that COVID testing occurs following a positive result in accordance with PA DOH COVID 19 Infection Control Outbreak Response Toolkit for Long Term Care.
- IP/Designees will conduct house audit of all COVID testing to ensure testing complete upon positive result.
- Regional Director of Clinical Services will conduct in-service regarding Infection Control and Outbreak Response testing procedures to facility Infection Preventionist and Director of Nursing.
- IP/Designee will conduct education to all staff regarding Infection Control and Outbreak Response testing procedures at their start of shift.
- DON/Designee will conduct audits to monitor for completion of testing for positive COVID results, daily for 14 days, then weekly for 4 weeks then monthly.
- Facility will ensure that return to work guidance for a staff member who tested positive for COVID is followed in accordance with PA DOH COVID 19 Infection Control and Outbreak Response Toolkit for Long Term Care.
- IP/Designee will monitor for any COVID positive staff weekly, monthly, and ongoing with occurrence, to ensure that return to work guidance for a staff member who tested positive for COVID is followed.
- IP/Designee will conduct education regarding return to work guidance for a staff member who tested positive for COVID is followed in accordance with PA DOH COVID 19 Infection Control and Outbreak Response Toolkit for Long Term Care.
- DON/Designee will conduct ongoing monitoring for COVID positive staff and monitor return to work status, weekly with outbreak occurrence in accordance with PA DOH COVID 19 Infection Control and Outbreak Response Toolkit for Long Term Care.
- IP/Designee to ensure that residents exhibiting signs and symptoms of Influenza are monitored in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care.
- IP/Designee will monitor all residents weekly, monthly and ongoing with occurrence for any sign and symptoms of Influenza in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care.
- Regional Director of Clinical Services will conduct Inservice regarding identification of Influenza signs and symptoms and testing in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care.
- IP/Designee will conduct education to all staff regarding identification of Influenza signs and symptoms and testing in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care.
- DON/Designee will conduct ongoing monitoring for Influenza signs and symptoms and testing, weekly with occurrence in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care.
- IP/Designee will conduct an initial audit of all residents' temperatures to ensure that residents exhibiting signs and symptoms of Influenza are monitored in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care.
- IP/Designee will monitor all residents' temperatures weekly, monthly and ongoing with occurrence for any sign and symptoms of Influenza in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care.
- Regional Director of Clinical Services will conduct Inservice regarding identification of Influenza signs and symptoms and monitoring in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care.
- IP/Designee will conduct education to all staff regarding identification of Influenza signs and symptoms and monitoring in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care.
- DON/Designee will conduct ongoing monitoring for Influenza signs and symptoms, weekly with occurrence in accordance with the PA DOH Influenza Outbreak Response Toolkit for Long Term Care.