Failure to Implement Infection Control Measures During RSV Outbreak
Penalty
Summary
The facility failed to implement effective infection prevention and control strategies for respiratory protection, specifically in response to an outbreak of Respiratory Syncytial Virus (RSV). Despite the onset of symptoms and positive RSV test results among multiple residents, the facility did not consistently initiate transmission-based precautions (TBP), such as isolation or droplet/contact precautions, at the onset of symptoms. For example, one resident with significant comorbidities including morbid obesity, COPD, and heart failure, developed respiratory symptoms and tested positive for RSV, but was not placed on appropriate precautions or monitored for ongoing symptoms. The care plan and physician orders did not reflect the need for TBP, and isolation was discontinued prematurely without a respiratory assessment to confirm symptom resolution. Several other residents developed respiratory symptoms and tested positive for RSV, yet their records did not show evidence of respiratory symptom screening, timely implementation of TBP, or consistent monitoring. In some cases, symptomatic residents were not isolated, and staff did not use personal protective equipment (PPE) when providing care. Residents with confirmed or suspected RSV were observed participating in communal dining and activities without masks, and staff failed to enforce isolation or mask use. The facility also lacked active screening protocols for early identification of new cases, and there was no comprehensive respiratory assessment or surveillance log tracking the spread of illness among residents. Interviews with facility leadership and staff revealed a lack of awareness and adherence to infection control policies and CDC guidelines. The Director of Nursing (DON) and Infection Preventionist were not fully informed about the outbreak status, did not conduct contact tracing, and were unaware of the number of cases that constituted an outbreak. Staff were not consistently educated or directed to monitor for respiratory symptoms, and there was no systematic process for implementing or removing TBP. The medical director was not notified of the outbreak in a timely manner, and the facility's infection control policies were not followed, resulting in a system-wide failure to prevent the spread of RSV.