Failure to Follow Contact Precautions During Norovirus Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program during a norovirus outbreak, specifically by not following transmission-based contact precautions for a resident on isolation. A community complaint reported that residents had norovirus, and the facility’s own policies required contact precautions, including use of appropriate PPE such as gowns and gloves, for residents with symptoms consistent with norovirus gastroenteritis. The facility’s Norovirus Prevention and Control policy directed that symptomatic residents be placed on Contact Precautions, ideally in single rooms or cohorted, and that these precautions continue for at least 48 hours after symptom resolution. The Infection Preventionist reported that a resident positive for norovirus had been admitted and that multiple residents subsequently developed GI symptoms, with 21 residents identified as having nausea, vomiting, or diarrhea and placed on contact precautions per RIDOH and Medical Director direction. Resident ID #4, who had dementia and had been readmitted to the facility in November 2025, had a physician’s order for contact precautions due to GI symptoms, and contact precaution signage was posted outside the resident’s room instructing staff to perform hand hygiene and wear a gown and gloves upon entry. During surveyor observation, a nursing assistant (Staff C) entered and exited this resident’s room without wearing a gown or gloves and failed to perform hand hygiene upon exit. Staff C then entered a clean linen storage room, handled clean linens, and re-entered the resident’s room still without appropriate PPE. In a subsequent interview, Staff C acknowledged awareness that the resident was on contact precautions for norovirus, recognized the posted signage, and admitted not following the required PPE and hand hygiene practices. Both the Infection Preventionist and the Administrator stated they expected staff to follow the posted contact precaution signage and wear appropriate PPE when entering the resident’s room.
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