Failure to Report Covid-19 Outbreak and Inadequate Infection Surveillance
Penalty
Summary
The facility failed to report a Covid-19 outbreak to the local health department as required by its own policy. After one resident was diagnosed with Covid-19 at the hospital, testing was conducted for all residents and staff on the affected hall, resulting in a second resident, who was the roommate of the first, also testing positive. Despite this, the local health department was not notified of the outbreak. Interviews with facility staff, including the Infection Preventionist and Director of Nursing Services, confirmed that the required notification did not occur. Additionally, the facility did not maintain adequate infection surveillance and tracking for two of three months reviewed. There was no infection control data available for one month, and incomplete tracking and lack of a monthly summary for another. In one case, a resident with an open abdominal wound and chronic kidney disease had multiple provider orders for urine testing to check for infection, but the tests were not completed in a timely manner. When the test was eventually performed, an infection was found and treated, but this infection was not included in the facility's infection control line list or tracked on the infection map. Staff interviews confirmed these lapses in infection tracking and timely testing.