Testing of symptomatic staff should be performed regardless of the outbreak investigation or exposure history.
Complete Contact Tracing
Complete Contact Tracing beginning 2 days before the Onset Date and continuing until the Positive Date. The employee may have been infectious before the Onset Date, generally considered to be a 48-hour period.
- Review medical records (including ADL documentation), staffing sheets, and assignments to identify affected residents and staff members.
- Residents with close contact (within 6 feet of the new employee case for 15 minutes or longer within a 24-hour period) and who are unable to tolerate wearing a mask are considered exposed and are placed in quarantine.
Identify any residents on the employee’s nursing unit with onset of COVID-19 in the 14 days before the employee’s Onset Date (suggesting an outbreak with nosocomial transmission).
Identify any staff on the employee’s nursing unit or in the employee’s department with onset of COVID-19 in the 7 days prior to the new case’s Onset Date (suggesting an outbreak with nosocomial transmission).
Interview Employee
Verify swabbing date and Positive Date, and symptom Onset Date.
Inquire about any exposures in the 7 days prior to onset, whether inside or outside of the nursing home, including with other staff members or on breaks.
- Community places or events where social distancing is difficult
- Carpooling or using public transportation
- Determine what specific care or services the employee provided to each resident on each day worked (starting 48 hours prior to Onset Date). Only include prolonged services, such as feeding, bathing, dressing, incontinence care, and interview. Do not include brief service, such as delivering medication or food tray, assistance with phone or TV remote, repositioning, transfer, transport.
- Consider these prolonged contacts as exposures and manage the residents as Exposed Residents.
- Notify the employee of the date through which they must remain out of work, and the dates of any needed Return to Work testing. If the employee is returned to work before Day 11 after the Onset Date, notify the employee of the date through which they need to wear a respirator or mask at all times.
For each resident and staff member identified as having an exposure, determine the First Exposure Date and Last Exposure Date starting 2 days before the Onset Date until the Positive Date. The first exposure date is the first worked day starting 2 days before the Onset Date until the Positive Date. The last exposure date is the last worked day starting 2 days before the Onset Date until the Positive Date. The date(s) of exposure determine the optimal time for exposure testing for that staff member.
- Exposed staff members should self-monitor for fever and symptoms of COVID-19 for 10 days and not report to work when ill or if testing positive for COVID-19 infection.
- For each staff member identified as having an exposure, calculate the date through which they need to wear a respirator (KN95 or N95) or well-fitting mask at all times, usually 10 days after the Last Exposure Date. Notify the staff member(s) of their masking requirements:
- Must wear a respirator (KN95 or N95) or well-fitting mask at all times when in the facility, removing the mask only when eating or drinking.
- Eating and drinking are only permitted in areas where residents are unlikely enter, and while physically distanced from all other people. Exposed staff members may not eat or drink in a resident care area.
- For each resident identified as having an exposure, calculate the date that Source Control (masking) or precautions can be removed following the guidance in COVID-19 Nursing Home Workflows.
- Report the above findings to the facility infection preventionist and the medical director(s).
Exposure Testing
In consultation with the infection preventionist and the medical director(s), identify residents and staff exposed by the new case for COVID-19 testing. Do not test any residents or staff within 1 month of the onset of confirmed COVID-19 illness.
Follow this guidance for any new cases identified:
- Test exposed staff, with a nasal specimen (Antigen (preferred) or PCR) every other day starting 1 day after the First Exposure Date and continuing until 6 days after the Last Exposure Date (usually a total of 3 tests).
- Test residents for COVID-19 (PCR test preferred, but Point-of-Care Antigen test is acceptable), regardless of vaccination status, who had an exposure to the new staff case.
- Test these exposed residents every other day starting 1 day after the First Exposure Date and continuing until 6 days after the Last Exposure Date (usually a total of 3 tests).
- For residents within 3 months of confirmed COVID-19 illness, Point-of-Care Antigen testing is used. Antigen testing reduces the possibility of identifying a “persistent positive” resident.
- Institute universal use of medical masks for all staff, visitors, and residents (if able to tolerate a mask) of the affected units or areas for 14 days after the Positive Date.
- Residents may decline testing.
- A registered nurse should provide counseling to the resident regarding the type of test used, the benefits of testing to the resident and the other facility residents, and the risks of declining testing. Document any resident declinations of testing and the counseling provided in the medical record.
- Residents who decline testing and have symptoms of COVID-19 illness should be isolated separately from residents who declined testing and do not have symptoms.
- Residents with an exposure who decline testing and are unable to tolerate wearing a mask are placed in Quarantine for 10 days after the exposure.
- A staff member that refuses testing is considered to have an outdated or incomplete health assessment and shall be prohibited from working for the nursing home or adult care facility until they complete testing.