Failure to Report COVID-19 Outbreak to Public Health Authorities
Penalty
Summary
The facility failed to report a COVID-19 outbreak to the California Department of Public Health (CDPH) as required by its own policy and state regulations. The outbreak involved three residents who tested positive for COVID-19 over a span of several days. Each resident had varying degrees of cognitive and physical impairment, and all were symptomatic at the time of testing. Documentation confirmed the positive test results and the presence of symptoms such as runny nose, cough, and weakness among the affected residents. Interviews with facility staff revealed confusion and miscommunication regarding the responsibility for reporting the outbreak. The Infection Preventionist (IP) believed another IP had reported the cases, while the Administrator assumed the IP had completed the notification. The Director of Nursing (DON) stated that the Department of Public Health had been notified, but was unable to provide documentation to support this claim. Another IP admitted to not knowing that reporting to CDPH was required and acknowledged that failing to report would result in a lack of outbreak support. A review of the facility's policy and procedure on communicable disease outbreaks indicated that the Administrator was responsible for reporting outbreaks to public health authorities. The policy defined an outbreak as one or more facility-acquired COVID-19 cases in a resident or three or more suspect, probable, or confirmed cases. Despite these clear guidelines, the facility did not notify CDPH of the outbreak, resulting in a failure to comply with both internal policy and regulatory requirements.