F0880

E

Failure to Implement Effective RSV Infection Control, Monitoring, and Reporting

Antioch, California Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and maintain an effective infection prevention and control program, including surveillance, during an RSV outbreak affecting multiple residents. Resident 1, admitted with diagnoses including pneumonia and COPD, tested positive for RSV in the hospital on 1/19/26 and was readmitted to the facility on 1/22/26. Upon readmission, Resident 1 was not placed on isolation precautions and was cohorted in a shared bedroom with two other residents during the RSV isolation period. The Infection Preventionist (IP) and DON stated the facility was unaware of the RSV diagnosis at the time of readmission because the hospital discharge documents were not uploaded into the EHR until 2/2/26, and the admitting nurse did not identify the RSV result, relying mainly on the nurse-to-nurse report and physician orders rather than reviewing the full discharge summary.

The facility also failed to assess and monitor RSV-positive residents during the isolation period. Resident 2, admitted with cerebral infarction and Alzheimer’s disease, tested positive for RSV on 1/29/26. Review of Resident 2’s EHR showed no documentation of change in condition assessments, monitoring, progress notes, or care plan interventions related to RSV management. The IP confirmed there was no documentation that the physician or responsible party were notified after Resident 2’s positive RSV test, and that Resident 2 was not assessed or monitored to evaluate progression of symptoms or response to infection. For Resident 1, the IP stated the resident was not monitored for RSV after readmission, and LVN 1 confirmed Resident 1 was not placed in isolation upon the last two readmissions.

The facility’s infection surveillance and reporting processes were also deficient. A facility-provided RSV record showed five residents tested positive for RSV within a 30-day period, but Resident 1, who was RSV-positive on 1/19/26, was not included on the RSV line list. The IP stated that more than two confirmed RSV cases should have been reported to public health authorities and acknowledged there was no formal or verifiable documented communication with local or state health departments regarding the RSV outbreak, recommendations, or guidance. The DON confirmed miscommunication among staff regarding RSV cases and acknowledged that nursing staff did not document Resident 2’s RSV status in the medical record. These practices were inconsistent with the facility’s written policies on RSV prevention, outbreak of communicable diseases, and infection prevention and control, which required monitoring for signs and symptoms, initiation of transmission-based precautions, surveillance and reporting of infectious diseases, and communication with public health authorities.