Failure to Implement Infection Control Measures During Influenza Outbreak
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices to prevent and contain the spread of influenza when three residents tested positive for influenza within a short period, affecting all 59 residents in the facility. The facility did not identify the presence of an outbreak, did not initiate droplet precautions, and failed to post appropriate signage or notify the local health department as required by policy and CDC guidance. Staff and family education regarding the outbreak was not provided, and the Infection Preventionist and clinical leadership did not verify isolation orders or monitor staff illness and infection-control compliance. Additionally, antiviral medications were not administered as prescribed, resulting in continued exposure and potential transmission of influenza throughout the facility. Specific failures included not implementing daily active surveillance for influenza illness among residents, healthcare personnel, and visitors after the first laboratory-confirmed case. Visual alerts and signage about respiratory hygiene and cough etiquette were not posted at entrances or in common areas, and symptomatic residents were not consistently placed on droplet precautions. Staff interviews revealed inconsistent use of personal protective equipment (PPE), with some staff wearing masks and others not, and Enhanced Barrier Precautions signage was used instead of droplet precautions for residents with confirmed influenza. Residents with flu-like symptoms were not always tested for influenza or offered antiviral treatment, and group activities and communal dining were not restricted during the outbreak. The facility also failed to implement Enhanced Barrier Precautions during high-contact care activities, such as catheter care, for a resident with an indwelling catheter. Staff did not consistently don gowns as required, and appropriate signage was not placed on resident doors. The Infection Preventionist was new to the position and was not present during critical periods of the outbreak, leading to a lack of oversight and documentation. The facility did not maintain a line list or illness log, did not track or trend new cases or staff illness, and did not provide in-service training specific to influenza precautions during the outbreak. These failures resulted in an Immediate Jeopardy situation, as determined by the surveyors.
Removal Plan
- All corrective actions to remove the Immediate Jeopardy (IJ) were completed