Failure to Implement COVID-19 Infection Control Measures
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices related to COVID-19, resulting in deficiencies in work exclusions for staff, contact tracing for residents, and the application of transmission-based precautions (TBP). Specifically, two employees who tested positive for COVID-19 returned to work before meeting the facility’s own policy requirements for return-to-work criteria, including the absence of two negative antigen tests. Both employees provided direct care to residents during their infectious periods, and there was no evidence that residents potentially exposed by these staff members were tested for COVID-19 as required by CDC guidance. Additionally, the facility did not conduct contact tracing for residents who were diagnosed with COVID-19, including those who had received aerosol-generating procedures or had close contact with other residents and staff. For example, residents who were hospitalized with COVID-19 or pneumonia did not have their close contacts identified or tested, and there was no documentation of universal source control measures, such as mandatory mask use, being in place during the outbreak. The facility also failed to implement TBP for residents who returned from the hospital with a recent COVID-19 diagnosis or who tested positive while in the facility, with delays or lack of documentation regarding the initiation of appropriate isolation precautions. Interviews with facility leadership confirmed these lapses, including the absence of contact tracing, lack of universal masking, and failure to follow both facility policy and CDC recommendations for testing and isolation. The report also notes that multiple residents and staff across two nursing units tested positive for COVID-19 within a short period, yet the facility did not initiate broad-based testing or enhanced precautions as outlined in national guidance. These actions and inactions directly contributed to the cited deficiencies in infection prevention and control.