Failure to Report COVID-19 Cases to State Agency
Penalty
Summary
The facility failed to follow its infection control policy and procedure by not reporting positive COVID-19 cases to the State Agency for two of three sampled residents. One resident, with diagnoses including diabetes mellitus, hypertension, hyperlipidemia, and major depressive disorder, had severe cognitive impairment and required significant assistance with daily activities. This resident experienced a change in condition with a fever, was tested for COVID-19 (result negative), transferred to the hospital, and later readmitted and tested for COVID-19 upon return. Another resident, with abnormalities of gait and mobility, hypertension, hyperlipidemia, and anemia, and moderate cognitive impairment, also required substantial assistance and was found to be COVID-19 positive after a change in condition. The Director of Nursing confirmed that these cases occurred within seven days of each other and acknowledged that they should have been reported to the State Agency, as required by the facility's infection prevention and control program policy. The policy specifically states the duty to notify appropriate government agencies of reportable contagious or infectious diseases. The failure to report these cases constituted a breach of the facility's established infection control procedures.