Failure to Report COVID-19 Outbreak to CDPH
Penalty
Summary
The facility failed to report a COVID-19 outbreak to the California Department of Public Health (CDPH) after three residents tested positive for COVID-19 on the same day. Resident 6, who had arthrogryposis multiplex congenita and required substantial assistance with activities of daily living (ADLs), tested positive for COVID-19. Resident 7, with a diagnosis of diabetes mellitus and moderate cognitive impairment, also tested positive, as did Resident 8, who had similar diagnoses and care needs. The positive test results for all three residents were documented on the same date, indicating an outbreak within the facility. Despite the facility's policy requiring the reporting of communicable disease outbreaks to appropriate agencies, including CDPH, the Infection Prevention Nurse reported the outbreak only to the local health department and not to CDPH. This omission was confirmed during interviews with both the Infection Prevention Nurse and the Director of Nursing, who acknowledged that such outbreaks should be reported to CDPH to ensure proper measures are taken. The facility's policy, dated December 2007, specifically mandates reporting of unusual occurrences, including communicable disease outbreaks, as required by federal or state regulations.