Failure to Timely Report COVID-19 Outbreak to CDPH
Penalty
Summary
The facility failed to notify the California Department of Public Health (CDPH) within 24 hours after identifying a COVID-19 outbreak involving two residents and one staff member. Record reviews showed that one resident, admitted with Parkinson's disease and failure to thrive, exhibited symptoms such as dizziness, sore throat, and runny nose and tested positive for COVID-19. Another resident, admitted with hypothyroidism, tested positive for COVID-19 but was asymptomatic. Both cases were identified on the same day, and a staff member also tested positive the following day. Despite receiving guidance from the Public Health Nurse (PHN) to report the outbreak to CDPH, the facility's Infection Preventionist Nurse (IPN) delayed reporting, believing that notifying the local public health office would suffice. Interviews with facility leadership confirmed awareness of the reporting requirement and the PHN's guidance. The IPN and Administrator acknowledged that the outbreak met the criteria for an unusual occurrence and should have been reported to CDPH within 24 hours, as outlined in the facility's policy. The delay in reporting resulted in CDPH not being informed in a timely manner, which prevented oversight and monitoring of the facility's infection control practices during the outbreak.