F0880

L

Failure to Implement Effective Infection Control During Concurrent Influenza, RSV, and COVID Outbreaks

Madison, Wisconsin Survey Completed on 01-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program during concurrent outbreaks of influenza, RSV, and COVID-19, affecting residents, staff, and visitors. The facility did not ensure appropriate physician orders or care plans were in place for multiple residents with confirmed respiratory infections, including influenza, RSV, and COVID. For one resident with a history of stroke and severe cognitive impairment who tested positive for both influenza and RSV, there were no orders addressing management of these infections and no care plan interventions, despite documented respiratory symptoms and positive lab results. This resident’s room lacked any droplet precaution signage, and a visitor entered and exited the room multiple times without performing hand hygiene or using PPE, with staff confirming the absence of signage indicating required precautions.

Another resident with Parkinson’s disease and severe cognitive impairment developed respiratory symptoms and later tested positive for influenza. Although a nurse’s note referenced discussion with the NP about Tamiflu and isolation time frames, the comprehensive physician order set contained no orders for transmission-based precautions, and the care plan did not address influenza management. This resident, who had an active order for Tamiflu, also had no droplet precaution signage on the room door. A third resident with dysphagia and a history of sepsis tested positive for influenza, yet had no related physician orders for infection management or TBP and no care plan addressing influenza. A fourth resident, cognitively intact and positive for COVID, had droplet precaution orders in place but no corresponding care plan for COVID management. A fifth resident with vascular dementia and dysphagia tested positive for COVID, but had no droplet precaution orders until several days after symptom onset and no care plan addressing COVID.

The facility’s leadership and infection control infrastructure were also deficient. The designated IP was not present in the facility during key survey dates and was unavailable for interview. The DON reported that she and the ADON were responsible for infection control when the IP was absent but stated they could not access or interpret the EMR infection tracking system and had only basic infection control training. The DON acknowledged she was not tracking residents with influenza, RSV, or COVID in an organized manner and was not tracking respiratory symptoms in non-infected residents. She also confirmed that isolation and droplet precaution orders and related care plans had not been entered for residents on droplet precautions for influenza, COVID, and RSV, and that symptom tracking for respiratory illness in all residents had not been occurring prior to a later date. When surveyors repeatedly requested outbreak documentation, including line listings, an outbreak management plan, and evidence of respiratory symptom tracking, the facility could not provide an outbreak management plan or documentation showing systematic tracking of non-infected residents. Infection control documentation from the EMR showed the outbreak status had not been updated for several days, and contact tracking had not been documented beyond its initial entry, despite multiple residents and staff reporting respiratory symptoms during the outbreak.

The Administrator and DON were unable to produce an outbreak management plan for the concurrent influenza and COVID outbreaks when interviewed. The DON stated she did not know why droplet precaution signage was missing from the doors of infected residents and reiterated that her expectation was that such signage should be present. A Regional Nurse Consultant confirmed that his expectation for outbreak management included appropriate documentation such as line listings, a functioning outbreak management plan, symptom tracking for staff and residents, and family notification of infection and outbreak status, but the facility lacked this documentation. The combination of missing orders and care plans for infected residents, absent or unclear isolation signage, lack of organized surveillance and tracking, and limited infection control oversight led to the determination of immediate jeopardy related to infection control.

The facility’s own policies required prompt identification and management of communicable disease outbreaks, defined thresholds for declaring an outbreak, and assigned responsibilities to the administrator, IP, DON, and staff for surveillance, initiation of transmission-based precautions, and communication with health authorities and families. Policies also required that when residents are placed on transmission-based precautions, appropriate notification be placed on the room entrance door and chart, and that visits to residents on influenza precautions be scheduled and controlled with instruction on hand hygiene and PPE. Despite these written policies, the facility did not implement them during the concurrent outbreaks, as evidenced by the lack of isolation signage, absence of documented TBP orders and care plans for multiple infected residents, and failure to maintain up-to-date outbreak tracking and symptom surveillance.

Staff symptom logs provided to surveyors showed multiple employees, including activity aides, housekeepers, CNAs, and an RN, reporting respiratory or flu-like symptoms over several days during the outbreak period. However, there was no evidence that this information was integrated into a broader outbreak management or surveillance system. The EMR infection control management system showed that outbreak status had not been evaluated or updated for several days, and contact tracking documentation had not been continued after its initial entry. These inactions, combined with the absence of a functioning outbreak management plan and the lack of systematic tracking of both infected and non-infected residents, contributed directly to the identified deficiency in the facility’s infection prevention and control program.

Overall, the deficiency centers on the facility’s failure to operationalize its infection control policies and CDC-based guidance during simultaneous outbreaks of influenza, RSV, and COVID. This included not ensuring that residents with confirmed infections had appropriate physician orders and individualized care plans, not posting required isolation signage, not maintaining organized surveillance and outbreak tracking, and not having adequately trained and available infection control leadership to manage the situation. These documented failures led surveyors to determine that immediate jeopardy existed under F880 for infection control.