Failure to Maintain Infection Prevention and Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by delayed and incomplete reporting of a COVID-19 outbreak to the state health department. Documentation shows that 12 residents tested positive for COVID-19 over a two-week period, but the facility did not notify the health department until nearly two weeks after the first case. When the line listing was eventually submitted, it included only residents and omitted staff members who had tested positive, despite explicit instructions from the health department to include both residents and staff. Interviews with facility leadership confirmed the delay in reporting and the omission of staff cases, and no written evidence was provided to support the facility's claim that staff cases did not need to be reported unless there were three or more. Additionally, the facility did not follow its own infection prevention and control policy regarding COVID-19. The policy required active monitoring of all residents for symptoms, prompt initiation of transmission-based precautions, and testing for SARS-CoV-2 in symptomatic individuals. However, multiple staff interviews revealed that, during the outbreak, the DON—reportedly following the medical director's direction—instructed staff to stop all COVID-19 testing for both residents and staff. Precautions were discontinued abruptly, and all symptoms were treated as common colds. Staff also reported that N95 masks were removed from use on the floors, and that the medical director did not believe in the necessity of COVID-19 precautions. These actions and inactions resulted in the facility failing to maintain a safe, sanitary, and comfortable environment, and not adhering to both regulatory requirements and its own policies for infection prevention and control. The failure to report cases accurately and to implement appropriate infection control measures had the potential to impact all residents and staff during the outbreak.