Failure to Exclude Symptomatic Staff Led to COVID-19 Outbreak
Penalty
Summary
The facility failed to implement and maintain an effective Infection Prevention and Control Program (IPCP) during a COVID-19 outbreak that affected all 58 residents on Unit A. According to the facility's IPCP policy, staff with communicable diseases were to be excluded from resident contact, and a system for staff to report illness and remain off work while symptomatic was required. However, record review and interviews revealed that symptomatic staff, including a Certified Nurse Aide and a housekeeper, continued to work while ill, which contributed to the onset and spread of the outbreak. The facility did not effectively identify and control the spread of infection, resulting in unit-wide clustered transmission and prolonged isolation precautions for residents. The Infection Preventionist confirmed that the outbreak began when symptomatic staff worked while sick, and that testing was conducted every three days until all residents tested negative. The Administrator acknowledged awareness of the outbreak and confirmed that staff and residents were repeatedly tested as new cases emerged. Despite these measures, the failure to exclude symptomatic staff from resident contact and to control the spread of infection led to many residents becoming symptomatic and required the isolation of all residents in their rooms due to ongoing transmission.