Failure to Report COVID-19 Outbreak and Ensure Visitor PPE Compliance
Penalty
Summary
The facility failed to implement required infection control practices in two key areas. First, the facility did not report a COVID-19 outbreak to the California Department of Public Health Licensing and Certification (CDPH L&C) as required by their own policy, despite having multiple residents and a staff member test positive for COVID-19 over a specified period. The Director of Nursing (DON) believed the Infection Preventionist had reported the outbreak, but did not verify this, and the Administrator later confirmed the outbreak was only reported to the local county, not to CDPH L&C. The facility's policy clearly stated that outbreaks meeting certain criteria must be reported to CDPH L&C. Second, the facility did not ensure that a resident's family member was educated on and compliant with infection control practices, specifically the use of personal protective equipment (PPE) while assisting a resident on contact precautions. During an observation, the family member was present in the resident's room and assisting with meals without wearing PPE, despite signage and facility policy requiring its use. The family member stated she was allergic to the gown and had not previously reported this issue. Staff confirmed that visitors were expected to wear PPE to prevent the spread of infection, and the facility's policy required donning gowns and gloves upon entry to rooms under contact precautions.