Failure to Isolate Resident Leads to Norovirus Spread
Penalty
Summary
The facility failed to ensure proper isolation of a resident with a suspected communicable infection, leading to the spread of Norovirus. Resident #2 was identified as having a suspected case of Norovirus during an outbreak in the facility. Despite the availability of open beds, Resident #2 was not moved to a separate room, and continued to share a room with Resident #1, who initially did not display any symptoms of the infection. Resident #1, who had diagnoses including Cervical Disc Disorder, Asthma, and Spinal Stenosis, was cognitively intact and required assistance with daily activities. Despite being placed on contact precautions, Resident #1 developed symptoms of Norovirus after remaining in the same room with Resident #2. The facility's policy required isolation or cohorting of infected residents, but this was not implemented effectively, as Resident #1 was not moved to an available bed to prevent cross-contamination. Interviews with the Director of Nursing and a Registered Nurse revealed that the facility did not move residents during the outbreak, despite guidance to separate symptomatic and asymptomatic residents. The Director of Nursing acknowledged that Resident #1 could have been moved to prevent infection, but stated that the virus was spreading rapidly. The facility's failure to isolate Resident #2 or move Resident #1 contributed to the spread of Norovirus, ultimately resulting in Resident #1's death from acute respiratory failure.
Plan Of Correction
Plan of Correction: Approved March 6, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **Plan of Correction FTAG 880** I. Immediate Action a. Resident #1 expired in the facility on [DATE]. Resident #2 is no longer residing in the facility and has been discharged to home on [DATE]. The Facility acknowledges that all residents on contact precautions/Isolation have the potential to be affected by this practice. b. The Director of Nursing received 1:1 re-education on [DATE] by the Regional Nurse on the Policy Infection Prevention and Control Program with emphasis on ensuring that all residents with a communicable infection, contact isolation are isolated immediately to prevent further spreading of the infection, utilizing all means, including room changes and cohorting as appropriate to ensure all residents' optimum health is maintained. II. Identification of Others a. An audit was conducted on [DATE] by the Infection Preventionist for residents on contact precautions/isolation to ensure all residents requiring contact isolation was in place and room placement was appropriate. No negative findings. III. System Changes a. The Policy and Procedure Titled Infection Prevention and Control Program dated [DATE] was reviewed on [DATE] and [DATE] by the Medical Director, Director of Nursing, Infection Preventionist, and the Administrator with no changes made. b. The Administrator, Assistant Administrator, Nursing Administration, Social Workers, Admissions personnel, and all nursing staff will be educated by the Educator/Designee on the Policy Titled Infection Prevention and Control Program dated [DATE] with emphasis on infection control, ensuring all residents with a communicable infection are isolated immediately to prevent further spreading of the infection utilizing cohorting and room change as appropriate to ensure all residents' optimal health is maintained. c. Registered Nurse #1 will be reeducated upon return to the facility [DATE] by the Staff Educator/designee on the Policy Infection Prevention and Control Program with emphasis on ensuring that residents with a communicable infection, contact isolation are isolated immediately to prevent further spreading of the infection, utilizing room change and cohorting to ensure all residents' optimum health is maintained. IV. Quality Assurance a. An audit tool was created by the Director of Nursing to review all residents placed on contact precautions to ensure staff are following infection control techniques, including isolating residents immediately, cohorting, and initiating room change when appropriate and completing patient-specific care plan with completed goals and interventions. b. Audits will be completed by the Infection Preventionist weekly x 8, then monthly x 2 months and quarterly thereafter until 100% compliance is achieved. c. All negative findings will be brought to the attention of the Director of Nursing immediately. All negative findings will be immediately addressed by the DNS/designee with an onsite teaching/Inservice and disciplinary action as needed. d. All results of the audits will be brought to the QAPI committee quarterly x 4 (to review and discuss any unfavorable patterns that may prevent achieving 100% compliance). V. Person Responsible Director of Nursing Completion Date: (MONTH) 12th, 2025