Failure to Cohort and Isolate COVID-19 Positive Residents
Penalty
Summary
Facility staff failed to maintain an effective infection prevention and control program, specifically in the management of residents who tested positive for COVID-19. Despite having a policy that directs staff to isolate or cohort residents with confirmed or suspected SARS-CoV-2 infection, staff did not consistently separate residents who tested positive from those who tested negative. Multiple observations showed that residents with positive COVID-19 test results were housed in the same rooms as residents with negative results, and neither group consistently wore masks. Additionally, COVID-positive residents were observed in common areas, such as hallways and dining rooms, in close proximity to other residents and staff. Interviews with residents and their representatives revealed that several residents were not asked if they wanted to move rooms when their roommate tested positive for COVID-19, despite expressing a preference not to share a room with an infected individual. Staff interviews indicated a lack of clear communication and awareness regarding which residents were COVID-positive. Some staff members, including a Certified Medication Technician and the Assistant Director of Nursing, were unaware of the COVID status of residents or the absence of appropriate signage and PPE disposal materials in affected rooms. The Infection Preventionist acknowledged that interventions such as room trays, some room changes, and mask usage had been implemented, but also noted that many residents refused to wear masks outside their rooms. Leadership interviews highlighted inconsistencies in staff education and communication regarding infection control protocols. While a list of COVID-positive residents was reportedly posted at the nurse's station, several staff members were unaware of it or did not know which residents required isolation or specific PPE. The Director of Nursing and Infection Preventionist were identified as responsible for ensuring compliance, but gaps in implementation and staff knowledge were evident throughout the facility.