Failure to Report COVID Outbreak and Lapses in Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control program as required, resulting in two specific deficiencies. First, during a COVID outbreak, the Infection Preventionist (IP) did not report the outbreak to the California Department of Public Health (CDPH) as required by facility policy, which states that communicable disease outbreaks must be reported to appropriate agencies within 24 hours. The IP reported the outbreak to the local public health office but did not notify CDPH, stating uncertainty about the reporting requirement. Second, a Certified Nursing Assistant (CNA) did not follow proper hand hygiene protocols while providing care to a resident who was dependent on staff for all activities of daily living and had multiple medical conditions, including respiratory failure, pneumonitis, dysphagia, aphasia, Alzheimer's disease, and diabetes. During incontinence care, the CNA failed to remove soiled gloves and perform hand hygiene before handling clean items and moving from a soiled to a clean body site. The CNA also did not perform hand hygiene after removing soiled gloves and before donning new gloves, contrary to facility policy and infection control standards.