Delayed Respiratory Testing and TBP Implementation for Symptomatic Residents
Penalty
Summary
The deficiency involves the facility’s failure to promptly implement its infection prevention and control policies for residents who developed respiratory symptoms. One resident with chronic obstructive pulmonary disease and pulmonary fibrosis, and with moderately impaired cognition and dependence on staff for several ADLs, developed shortness of breath, coughing, and congestion as documented on an SBAR form on 2/14/2026 at 9:30 p.m. Despite these symptoms, the resident was not placed on transmission-based precautions until 2/18/2026 at 8:33 p.m., and testing for a respiratory pathogen panel was not performed until 2/19/2026 at 5 a.m. The Infection Prevention Nurse (IPN) confirmed during interview and record review that this resident should have been tested for a respiratory pathogen panel or at least influenza and Covid-19 immediately when symptoms appeared and should have been placed on transmission-based precautions right away. Another resident, admitted with acute pulmonary edema and anemia, also had moderately impaired cognition and required set-up assistance with eating and oral hygiene and was dependent on staff for showering and toileting hygiene. This resident developed a productive cough documented on an SBAR form on 2/21/2026 at 8:29 p.m., but testing for a respiratory pathogen panel was not completed until 2/23/2026 at 3:30 a.m. The IPN confirmed that this resident likewise should have been tested for a respiratory pathogen panel or at least influenza and Covid-19 immediately when respiratory symptoms manifested. The facility’s own infection prevention and control policy stated it would maintain a safe environment to prevent and manage the spread of infections and follow current best practices, and the LA Department of Public Health toolkit specified that residents with signs or symptoms of respiratory illness should be immediately tested for Covid-19 and influenza and placed on empiric transmission-based precautions while awaiting results. The surveyors determined that these delays constituted a failure to implement infection control policies and public health guidance.
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