Failure to Test Symptomatic Resident for COVID-19 per Facility Protocol and CDC Guidance
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program and CDC guidance for testing residents with new respiratory symptoms. A female resident with dementia, dysphagia, and chronic kidney disease was admitted on an unspecified date and later developed respiratory symptoms. On 12/29/25, a physician communication note documented that the resident presented with a congested cough, rhonchi throughout both lungs, and some weakness. The resident had existing physician orders dated 12/20/25 and 12/26/25 for SARS-CoV-2 (COVID-19) testing as needed per facility protocol, but there was no evidence that a COVID-19 test was ordered or performed after the onset of these symptoms. A complaint submitted to the State Agency on 1/28/26 stated that the resident was transferred to an emergency room on 1/8/26 with severe respiratory issues and was confirmed COVID-positive, and that the nursing home did not test her when she first showed symptoms, treating her only for pneumonia. During interviews, the ADON/Infection Preventionist explained that symptomatic residents should be tested for COVID-19 per facility protocol and identified symptoms warranting testing as sore throat, congestion, cough, fever, and fatigue. The ADON/IP confirmed that the resident was not tested for COVID-19 after respiratory symptoms began on 12/29/25 and stated that because the resident was being treated for pneumonia, it had “slipped my mind” to test for COVID-19, acknowledging that the resident should have been tested at symptom onset. This failure was inconsistent with the facility’s written Infection Prevention and Control Program, which required viral testing for anyone with even mild COVID-19 symptoms, and with CDC guidance directing testing of residents and HCP with new respiratory illness signs or symptoms.
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