Failure to Initiate Contact Tracing and Testing After COVID-19 Case
Penalty
Summary
The facility failed to follow its infection prevention, response, and reporting policy after a resident tested positive for COVID-19. The resident, who had multiple diagnoses including COVID-19, was identified as positive on 4/14/2025, with documentation showing that the Power of Attorney was notified and COVID isolation precautions were initiated. However, the Infection Preventionist (RN) stated that she was not aware that contact tracing and testing were required following the positive result and confirmed that these steps were not taken. The Director of Nursing verified that contact tracing and testing should have been initiated immediately after the positive case was identified. The facility's policy, reviewed on 10/1/2024, requires evaluation of potential exposures and either contact tracing or a broad-based testing approach for all residents and health care providers identified as close contacts or on the affected unit. Despite this, no contact tracing or testing was performed after the resident's positive COVID-19 result, and staff were noted to work throughout the facility, increasing the potential for exposure. The failure to implement these required infection control measures had the potential to affect all 108 residents in the facility.