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New Resident Case

New Resident Case

One case of COVID-19 in a nursing home is considered an outbreak. The goals of outbreak investigation are (1) to identify potential asymptomatic sources of COVID that caused the outbreak and (2) to identify other asymptomatic cases involved in the outbreak, minimizing further exposures and facilitating care processes and cohorting, when possible. Testing of symptomatic residents and staff should be performed regardless of the outbreak investigation or exposure history.

Definitions:

Onset Date: The date the COVID test swab was done, or the date of onset of symptoms, whichever is earlier.
Positive Date: The date the COVID test result was reported. If the person was placed on isolation precautions prior to the date of the test result, use the date that isolation precautions started.

Protocol:

  • Interview resident, if resident is able to be interviewed:
    • Verify symptoms and symptom onset
    • Inquire about any other residents or visitors who were within 6 feet of the resident for more than 15 minutes total over a 24-hour period from 48 hours before the onset date until the positive date.
  • Review the medical record for any activities representing potential exposure events from 48 hours before the Onset Date until the Positive Date. Include a review of assessments, progress notes, care plan, dining seating plans, and activity attendance records.
    • Communal dining or activities, and the other residents that attended. Consider those residents as exposed and place them in quarantine if they are unable to tolerate wearing a mask. The resident may have been infectious before the Onset Date, generally considered to be a 48-hour period.
    • Trips outside of the facility, including office visits, procedures, and hospitalizations. Notify the staff at the destination of the potential exposure.
    • Dialysis. Notify the dialysis staff of the potential exposure.
    • Physical, Occupational, or Speech Therapies
    • Dental care
    • Eye care
  • Review the facility visitor log for any potential exposure events in the 2 days prior to the Onset Date or between the Onset Date and the Positive Date. Notify them of the potential exposure.
  • Review staffing sheets, assignments, and medical record entries (including ADL documentation) to identify any staff members who had an exposure to the resident, starting 2 days prior to the Onset Date up to the Positive Date.
    • For each staff member identified, determine what specific care or services were provided to the resident. Only include staff members who provided prolonged services, such as feeding, bathing, dressing, incontinence care, or interview. Do not include staff members who only provided brief service, such as delivering medication or food tray, assistance with phone or TV remote, repositioning, or transfer.
    • Screen each exposed staff member for symptoms of COVID-19.
  • Identify all residents who were roommates of the new resident case in the time period starting 48 hours before the onset date until the positive date. These roommates are considered exposed – follow “Exposed Resident” workflow.
  • 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 mask at all times, usually for 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 cannot 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.
  • Identify any residents on the resident’s nursing unit with onset of COVID-19 in the 14 days prior to the resident’s onset date (suggesting an outbreak with nosocomial transmission).
  • Identify any staff on the resident’s nursing unit with onset of COVID-19 in the 14 days prior to the resident’s onset date (suggesting an outbreak with nosocomial transmission).
  • Identify residents who share the same day shift CNA assignments as the new resident case. Do not consider these residents exposed if they had no other contact with the new resident case. Residents on the same assignment may have had similar exposures and should receive asymptomatic targeted testing.
  • Report the above findings to the facility infection preventionist and the medical director(s).
  • Targeted Testing: Other residents with similar exposures to the new resident case may have unrecognized COVID-19 infection. Identify residents with the same day shift CNA assignments as the new resident case. Do not test any residents within 1 month of the onset of confirmed COVID-19 illness or who are being tested for an exposure.
    • Test identified residents once who have not had COVID-19 illness in the previous 3 months for COVID-19 (PCR test preferred, but Point-of-Care Antigen test is acceptable).
    • Test identified residents once who have had COVID-19 illness in the previous 3 months with an Antigen test for COVID-19.
  • Exposure Testing: In consultation with the infection preventionist and the medical director(s), identify residents and staff exposed by the new case, for exposure COVID-19 testing. Do not test any residents or staff within 1 month of the onset of confirmed COVID-19 illness.
    • 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 exposed residents for COVID-19 (PCR test preferred, but Point-of-Care Antigen test is acceptable), regardless of vaccination status, who:
      • Were roommates of the new resident case.
      • Participated in the same service or activity as the new case starting 2 days before the Onset Date until the Positive Date.
    • 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 until they complete testing.