F0880

E

Failure to Report Influenza Outbreak to State Survey Agency

San Antonio, Texas Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to establish and maintain an infection prevention and control program that included required reporting to the state survey agency of an influenza outbreak affecting 13 residents. Complaint Intake Investigation Worksheet #1067849 alleged that multiple residents were diagnosed with influenza and that there was no self-report of the outbreak to the state agency. Review of the state’s TULIP system on 02/06/2026 showed no self-reported incidents regarding an active influenza outbreak, despite facility records documenting that 13 residents tested positive for influenza A between 01/26/2026 and 02/05/2026. The report states that the DON and Administrator failed to report these positive influenza cases to the state survey agency.

Record review of the facility’s Symptomatic Testing log showed that 13 residents developed symptoms, were tested, and were confirmed positive for influenza A over a span of several days. One resident developed cough and congestion on 01/25/2026, was tested the next day, and was found positive for influenza A, with droplet isolation and antiviral treatment initiated. Two other residents developed fever and respiratory symptoms on 01/26/2026, were tested, and were later confirmed positive for influenza A, with isolation and Tamiflu ordered. Additional residents on the same hall and on another hall developed symptoms such as fever, cough, congestion, and changes in condition, were tested for influenza, and were confirmed positive, with droplet isolation precautions and antiviral therapy documented in their clinical records.

Several residents were sent to the emergency room where they were also diagnosed with influenza A, including one resident who was transferred due to low blood pressure, tachycardia, and fever and was diagnosed with sepsis due to influenza A in the hospital. Another resident was evaluated in the ER after a fall and was diagnosed with influenza A there. Across all 13 residents, the facility’s records consistently documented positive influenza A test results, initiation of droplet isolation precautions, and orders for Tamiflu. Despite this cluster of confirmed influenza A cases and the presence of an active outbreak, there was no corresponding self-report of the outbreak in the state reporting system, as confirmed by review of TULIP, and the report explicitly states that the DON and Administrator did not report these cases to the state survey agency.

The residents involved had multiple comorbidities, including paraplegia, dementia, schizophrenia, diabetes, hypertension, heart disease, Parkinson’s disease, malnutrition, and cognitive communication deficits. Some residents had received the influenza vaccine, while others had refused it, and care plans for many residents included monitoring for signs and symptoms of influenza. Nursing notes and physician orders documented changes in condition such as fever, cough, congestion, weakness, increased confusion, and abnormal vital signs, followed by testing and confirmation of influenza A. These documented clinical events and positive test results, combined with the absence of any self-reported outbreak in the state system, form the basis of the cited deficiency in the facility’s infection prevention and control program related to required reporting.

The report states that this failure to report could put residents at risk of neglect, illness, communicable diseases, respiratory distress, and harm. The deficiency is specifically tied to the inaction of the DON and Administrator in not reporting the influenza outbreak to the state survey agency, despite clear evidence of an outbreak in facility records. The findings are based on observation, interview, and record review, and encompass all 13 residents reviewed for infection control reporting requirements.