Failure to Implement Effective Infection Control During Influenza A Outbreak
Penalty
Summary
The facility failed to implement effective infection prevention and control strategies for respiratory protection, specifically in response to an outbreak of Influenza A. There was a lack of ongoing monitoring and screening of residents with respiratory symptoms, and transmission-based precautions (TBP) were not consistently or promptly implemented for symptomatic residents. Documentation revealed that TBP were often delayed, not initiated at symptom onset, or removed without comprehensive assessment and monitoring for symptom resolution. In several cases, residents with symptoms were not placed on appropriate precautions until days after symptom onset or after laboratory confirmation, and there was no consistent documentation of respiratory assessments or the rationale for removal of precautions. Multiple residents with complex medical histories, including conditions such as hemiplegia, diabetes, COPD, morbid obesity, and immunodeficiency, developed symptoms consistent with influenza and subsequently tested positive. Several residents required hospitalization due to complications. The facility's infection control records did not reflect timely or comprehensive surveillance, and there was no evidence of active respiratory symptom screening for residents who were exposed or symptomatic. Staff interviews confirmed that assessments were not always documented, and infection tracking logs were incomplete, missing key information such as the start and end dates of TBP and not including all symptomatic residents. Direct observations revealed staff entering rooms of residents on contact and droplet precautions without donning the required personal protective equipment (PPE) as indicated by signage. Staff demonstrated inconsistent understanding and adherence to infection control protocols, with some staff only wearing masks when full PPE was required. Housekeeping staff were also observed failing to follow proper PPE and hand hygiene protocols when cleaning rooms of residents on precautions. These failures contributed to the spread of Influenza A within the facility, resulting in an outbreak affecting multiple residents and leading to an immediate jeopardy situation due to the risk of further transmission.