F0880

E

Failure to Implement Effective Infection Prevention and Control for RSV

Port Angeles, Washington Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive Infection Prevention and Control Program (IPCP) based on facility-specific and community-based risk assessment, and to timely prevent, identify, and respond to respiratory symptoms in a resident. Resident 1, who was moderately cognitively impaired, complained of breathing discomfort and chest pain on 02/01/2026 and was sent to the hospital, returning the same day with a diagnosis of RSV. An EMT later reported that Resident 1 had yellowish, vomit-smelling liquid all over their body, with the bed, floor, and bedside wall covered in dry yellow liquid, and that staff entering and exiting the room were not wearing PPE or using any precautions. Upon Resident 1’s return, the EMT stated the room appeared unchanged and had to be cleaned with disinfecting wipes found outside the room, while Resident 1’s roommate remained in the shared room without infection precautions in place.

On 02/04/2026, a Contact Precautions sign was observed on the door to the room, but staff were seen exiting without gloves or gowns and without performing hand hygiene before proceeding to other tasks and rooms. When questioned, the RN did not know why the Contact Precautions sign was posted and incorrectly associated it with the presence of a foley catheter, further stating they did not know who was responsible for signage and that the facility did not have a good infection control program. The DNS later stated that Resident 1 should have been placed on a combination of Droplet and Contact Precautions upon return from the hospital and that the room should have been thoroughly cleaned and disinfected.

The DNS reported that an RN had been designated as the Infection Preventionist in December 2025 after the previous IP left, but this RN stated they had not been trained and did not have time to perform IP duties. The DNS also did not know where any of the IPCP information was. Following Resident 1’s RSV diagnosis and subsequent death, additional residents with severe cognitive impairment (Residents 2, 3, 4, and 5) later tested positive for RSV, with documentation of respiratory distress, increased temperature, decreased oxygen saturation, and hospital transfers. The Regional Nurse Consultant stated that the lack of a comprehensive IPCP, the lack of a credentialed and trained IP, and the lack of infection control training and education for staff all contributed to the RSV outbreak and its severity.