Failure to Maintain Infection Prevention and Control During COVID-19 and Gastroenteritis Outbreaks
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in deficiencies during outbreaks of COVID-19 and gastroenteritis. Surveyors found that the facility did not complete line listings contemporaneously, with discrepancies between comprehensive and COVID-19-specific lists, and missing or inconsistent information such as resident names, dates of onset, and dates of removal from precautions. The facility also failed to document why testing was conducted when residents were asymptomatic and did not track residents with symptoms, only those who tested positive. Routine screening for COVID-19 symptoms among residents was not performed daily, nor was it increased to every shift during the outbreak as required. The facility did not document when residents were removed from isolation precautions after a positive COVID-19 test, and there was confusion among staff regarding the criteria for discontinuing precautions. Additionally, the facility did not recognize a gastroenteritis outbreak among staff, despite multiple staff members exhibiting gastrointestinal symptoms within a short timeframe, and failed to implement outbreak control measures. Documentation for staff with gastroenteritis symptoms was incomplete, with missing last symptom dates and return-to-work dates, resulting in staff returning to work too soon after illness. In several cases, staff did not remain out of work for the required period following symptom resolution, and there was no clear process for determining when it was safe for staff to return. These failures were confirmed through interviews with the DON and Regional Clinical Director, who were unable to provide consistent explanations for the discrepancies and lapses in infection control practices.