Failure to Implement Effective Infection Control During Norovirus Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a Norovirus outbreak, resulting in the spread of the virus to all three nursing units, affecting 27 out of 61 residents and 33 out of 86 staff members. Surveyors observed multiple instances where staff did not follow established infection control protocols, such as failing to don appropriate personal protective equipment (PPE), not performing hand hygiene, and not posting or following correct isolation signage. In several cases, residents with indwelling devices or active gastrointestinal symptoms did not have Enhanced Barrier Precautions (EBP) or Contact Precautions signage or PPE carts at their room entrances, and staff were unclear about which precautions were required. The facility did not promptly report the Norovirus outbreak to the State Survey Agency or the local health department as required. The Infection Preventionist was unaware of the need to notify the State Survey Agency and only contacted the Department of Health ten days after the first case was identified. Additionally, the local health department confirmed that outbreak reporting was required and had not been received. Communication breakdowns were evident, as staff were not consistently reporting new cases of illness among residents and staff to the Infection Preventionist, and the outbreak line list was incomplete, missing several affected individuals. Staff members who became ill with Norovirus were instructed to return to work after being symptom-free for only 24 hours, contrary to CDC guidelines recommending a 48-hour exclusion. There were also instances where staff worked while still symptomatic, including one LPN who worked a double shift with a documented fever. Staff interviews revealed confusion regarding the use of PPE, the difference between EBP and Contact Precautions, and inconsistent practices in posting and following precaution signage. The facility's infection prevention policies were not clearly reviewed or updated, and staff were unsure who was responsible for policy review.