F0880

E

Failure to Follow Influenza Testing Policy During Outbreak

Red Bluff, California Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The facility failed to implement its Influenza Exposure Control policy when multiple residents tested positive for Influenza A and timely, comprehensive testing of exposed residents was not conducted. The policy, revised in January 2026, required a multifaceted approach to preventing influenza transmission, including testing ill persons in both affected and previously unaffected units. Four residents with significant comorbidities, including respiratory failure, COPD, pneumonia, dementia with agitation, diabetes, heart disease, chronic kidney disease, and cirrhosis, were confirmed positive for Influenza A. The Infection Prevention Nurse (IP) reported that the facility first became aware of influenza in the building when notified by a local hospital that one resident was positive, and also stated that the facility initially had no influenza test kits on hand.

The IP acknowledged that she only tested residents who shared rooms with influenza-positive residents and those with flu-like symptoms, and confirmed she did not review the facility’s influenza exposure policy before determining who to test. A consulting RN, who had been at the facility for about a week, confirmed she advised the IP without reviewing the facility’s policy and later acknowledged that more residents should have been tested. The DON confirmed that the facility was not prepared for an influenza outbreak, that the influenza policy was not followed for resident testing, and that all residents should have been tested because they dined and participated in activities together and there were sick employees. The report states that this failure to follow the infection control policy for testing put residents, staff, and families at risk for contracting Influenza A and had the potential to result in serious negative clinical outcomes.