Failure to Timely Report Respiratory Illness Outbreak to Public Health Authorities
Penalty
Summary
The facility failed to comply with state and local public health authority requirements for timely reporting of a respiratory illness outbreak. Between 3/30/25 and 4/8/25, a total of 11 residents and 3 staff members exhibited symptoms such as cough, runny nose, sore throat, and shortness of breath, with some being diagnosed with pneumonia or bronchitis and others requiring hospital transfer. Despite the facility's policy requiring prompt communication and determination of reportable infections, the outbreak was not reported to the California Department of Public Health (CDPH) until 4/8/25, exceeding the required 24-hour reporting timeframe outlined in state regulations. Record review and interviews confirmed that the Infection Preventionist (IP), who was new to the position, did not submit the outbreak report to CDPH until several days after the initial cases were identified. The facility's own infection control surveillance policy and the State Operations Manual both require immediate action and reporting when a communicable disease outbreak is suspected. The delay in reporting was acknowledged by the IP during the survey, and the facility's documentation showed a clear timeline of symptom onset and diagnoses among residents and staff prior to the eventual notification to public health authorities.