Failure to Complete Contact Tracing and Outbreak Testing for COVID-19 Cases
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as required, specifically by not completing contact tracing and outbreak testing for two residents who tested positive for COVID-19 in February 2025. Facility policies required identification of exposed individuals, documentation of contacts, and outbreak testing every 48 hours for those exposed, but these procedures were not followed. The facility was unable to provide documentation of who had been exposed to the infected residents or when exposed individuals were tested, and the available COVID-19 testing log was incomplete and did not clarify whether the tests performed were related to the outbreak or were precautionary. Both affected residents had severe cognitive impairment and were symptomatic at the time of their positive COVID-19 tests. Interviews with the DON/Infection Preventionist and consulting staff confirmed that contact tracing and outbreak testing should have been conducted and documented, but they were unable to produce the required records or logs. The lack of documentation and incomplete testing logs indicated that the facility did not follow its own policies or CDC guidelines for managing COVID-19 outbreaks, resulting in a failure to prevent potential transmission of communicable diseases.