Failure to Manage Norovirus Outbreak, Perform Hand Hygiene, and Annually Review Infection Control Policies
Penalty
Summary
Facility staff failed to implement appropriate infection control measures during a cluster of residents with nausea and vomiting consistent with a Norovirus outbreak. Within a five‑day period, four residents on one floor and one resident on another floor developed vomiting, often with undigested food particles, and some required PRN Zofran or transfer to the ER for evaluation and treatment. These residents, including those with significant cognitive impairment and dependence for ADLs, remained in semi‑private rooms with roommates who were initially asymptomatic. The daily census showed that unoccupied rooms were available, yet there was no documented evidence that symptomatic residents were moved to private rooms or separated from unaffected roommates. One resident became ill after being allowed to cohort with a roommate who had exhibited vomiting the previous day. In an interview, the infection preventionist stated they believed it was an isolated incident and did not think affected residents needed to be moved. Facility staff also failed to perform required hand hygiene while handling meal trays and providing set‑up and feeding assistance to three residents. During a breakfast observation, a CNA delivered and set up trays for one resident, then for a second resident, and then for the second resident’s roommate, including raising bed heads, repositioning bedside tables, removing dome covers, unwrapping utensils and straws, opening milk cartons, cutting food, and providing direct feeding assistance, all without performing hand hygiene between residents or between contact with residents’ environments. The facility’s hand hygiene policy required hand hygiene before touching a resident, before preparing or handling food, after touching a resident, and after touching a resident’s environment, and specified ABHR as the preferred method unless hands were visibly soiled. When interviewed, the CNA stated she must have forgotten, and the unit manager and DON acknowledged the observations. In addition, the facility did not conduct an annual review of two infection control policies related to COVID‑19. The “COVID‑19 Resident Vaccination Policy” showed a revision date of June 1, 2022, and the “COVID‑19 PPE, source control for Healthcare personnel” policy showed a revision date of June 2023, with no evidence of annual review as required by the facility’s infection prevention and control program. During an interview, the infection preventionist acknowledged these findings and stated that they wait to receive updates from the regional office.
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