Failure to Report COVID-19 Outbreak to State Agency
Penalty
Summary
The facility failed to report a COVID-19 outbreak to the State Agency as required by federal and state regulations. Multiple residents tested positive for COVID-19 over a period of time, with laboratory results confirming positive cases for six residents. The infection prevention nurse (IPN) acknowledged that the outbreak began when three residents tested positive and reported the incident to the local public health agency and the CDC's National Healthcare Safety Network, but did not notify the State Agency. The IPN believed that reporting to the local agency would automatically result in notification to the State Agency. Further review revealed that the Director of Nursing (DON) was not aware that the State Agency required direct notification and only realized this after reviewing the relevant All Facilities Letter (AFL 23-08), which clarified the reporting requirements. The facility's own policy and procedure on infection outbreak response indicated that outbreaks should be reported to local and/or state health departments in accordance with state requirements, but this was not followed in practice. The residents involved had various medical conditions, including pneumonia, prostate cancer, atrial fibrillation, coronary artery disease, congestive heart failure, stage 4 kidney disease, lupus, hypertension, colon cancer, bronchitis, morbid obesity, and hyponatremia. Some residents had moderate cognitive impairment, while others were cognitively intact. The failure to report the outbreak to the State Agency was identified through observation, interviews, and record review, and was considered a deficiency in the facility's infection prevention and control program.
Plan Of Correction
F880 - Infection Control Program How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On 6/2/25, the Infection Prevention Nurse (IPN) initiated the reporting of COVID-19 outbreak to California Department of Public Health (CDPH). Exhibit #27 How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: - Not applicable What measures put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 6/2/25, the Director of Nursing (DON) provided one-on-one in-service to the IPN regarding the facility policy and procedure entitled, "Infection Outbreak Response and Investigation," dated 12/19/2022. (Exhibit #28) - Starting on 6/2/25, the IPN will review the number of cases daily until the outbreak is over and report to CDPH accordingly. - Beginning on 6/2/25, the IPN will report to the CDPH the COVID-19 outbreak. - On 6/13/25, the IPN received Respiratory Illness Outbreak clearance letter. (Exhibit #29) How the facility plans to monitor its performance to make sure that solutions are sustained: - The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. - The IPN will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified after. - Date of completion: June 20, 2025