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New Resident Case
New Resident Case
Worksheet: New Resident Case
One resident 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 SARS-CoV-2 test swab was collected, or the date of onset of COVID-19 symptoms, whichever is earlier.
Positive Date: The date the SARS-CoV-2 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 date.
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 2 days before the onset date until the positive date.
Review the medical record for any activities representing potential exposure events from 2 days before the Onset Date until the Positive Date. Include a review of assessments, progress notes, care plan, dining seating plans, and activity attendance records. The resident may have been infectious before the Onset Date, generally considered to be a 2-day period.
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.
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 2 days 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 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.
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).
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.
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 until they complete testing.
New Employee / Staff Case
New Employee / Staff Case
Worksheet: New Staff Case
Testing of symptomatic staff should be performed regardless of the outbreak investigation or exposure history.
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 2 day 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, 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
Determine what specific care or services the employee provided to each resident on each day worked (starting 2 days 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) immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. If the facility is notified of the exposure more than 6 days after it occurred, contact your medical director or the regional epidemiologist for instructions regarding the frequency and duration of testing.
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 immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. If the facility is notified of the exposure more than 6 days after it occurred, contact your medical director or the regional epidemiologist for instructions regarding the frequency and duration of testing.
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 until they complete testing.
New Visitor Case
New Visitor Case
Worksheet: New Visitor Case
Complete Contact Tracing beginning 2 days prior to the Onset Date and continuing until the 14 days after the Onset Date or the last visit to the facility, whichever is earlier. The visitor may have been infectious before the Onset Date, generally considered to be a 2 day period.
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. Identify all residents visited by the visitor.
Interview visitor:
Verify swabbing date and Positive Date, date(s) of visit(s), and symptom Onset Date.
The duration of the visit, any close contact with the resident, and mask use.
Any other residents, staff or visitors who were within 6 feet of the visitor for more than 15 minutes total over a 24-hour period, and if PPE was used.
Inquire about any of the visitor’s other contacts or family members who have visited the facility or may visit the facility. Begin investigations for all such contacts.
If the visitor entered any resident unit or other areas of the building where residents were present.
Interview resident(s) visited by the visitor case.
Duration of the visit, close contact with the visitor, and mask use.
Any other residents, staff or visitors who were within 6 feet of the visitor for more than 15 minutes total over a 24-hour period, and if PPE was used.
If the visitor entered any resident unit or other areas of the building where residents were present.
Interview staff on duty during the visitor’s visit(s).
Duration of the visit, close contact with the visitor, and mask use.
Any other residents, staff or visitors who were within 6 feet of the visitor for more than 15 minutes total over a 24-hour period, and if PPE was used.
If the visitor entered any resident unit or other areas of the building where residents were present.
Report the above findings to the facility administrator, infection preventionist, and the medical director(s).
The resident(s) and staff member(s) who received the visit(s) should be treated as exposed.
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.
Exposure Testing: In consultation with the infection preventionist and the medical director(s), identify residents and staff exposed by the new visitor case, for exposure COVID-19 testing, regardless of vaccination status. 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) immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. If the facility is notified of the exposure more than 6 days after it occurred, contact your medical director or the regional epidemiologist for instructions regarding the frequency and duration of testing.
Test exposed residents for COVID-19 (PCR test preferred, but Point-of-Care Antigen test is acceptable) who received visits within 2 days of the Onset Date.
Test these exposed residents immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. If the facility is notified of the exposure more than 6 days after it occurred, contact your medical director or the regional epidemiologist for instructions regarding the frequency and duration of testing.
For residents within 3 months of confirmed COVID-19 illness, use Point-of-Care Antigen testing. Antigen testing reduces the possibility of identifying a “persistent positive” resident.
Residents may decline testing.
A registered nurse will 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.
New Resident or Staff Case, Unable to do Contact Tracing
(Broad-based Approach)
New Resident or Staff Case, Unable to do Contact Tracing
(Broad-based Approach)
Contact tracing is less effective in a larger outbreak (more than 3 new resident or staff cases within 7 days) and when adequate numbers of staff trained to do the contact tracing are not available. In these situations CDC recommends a broad-based approach, which is a geographic approach to outbreak management. Consult the medical director(s) when abandonment of contact tracing is considered.
Identify Residents and Staff for geographic outbreak management. Determine the geographic areas of the facility where positive residents and/or staff were present, starting 2 days before the most recent case Onset Date. If over 75% of the facility is affected, test all facility residents and staff. Include all staff who routinely enter these areas or are assigned to these areas, including non-clinical staff and staff from non-nursing disciplines.
All staff members should self-monitor for fever and symptoms of COVID-19 for 14 days after the most recent Onset Date and not report to work when ill or if testing positive for COVID-19 infection.
All residents in the affected geographic areas who are unable to tolerate wearing a mask are placed in quarantine for 14 days after the most recent case Positive Date. Follow Exposed Resident workflow.
All staff members in the affected geographic areas should wear eye protection (face shield) when within 6 feet of a resident, and a respirator (not a mask) at all times for 14 days after the most recent case Positive Date. Notify the staff member(s) of their respirator and eye protection requirements:
Must wear a respirator (not a mask) at all times when in the facility, removing the respirator only when eating or drinking.
Must wear eye protection when within 6 feet of a resident.
Eating and drinking are only permitted in areas where residents are unlikely enter, and while physically distanced from all other people. These staff members may not eat or drink in a resident care area.
Test all identified residents and staff for COVID-19 every other day until at least 3 tests are performed. If additional cases are identified, test all identified residents and staff every 2-3 days for 10 days after the most recent case Onset Date.
Test staff with a Point-of-Care Antigen or PCR COVID-19 test.
Test residents for COVID-19 (PCR test preferred, but Point-of-Care Antigen test is acceptable).
Document all residents and staff identified for testing and the dates and results of all tests. Consider using a Heat Map to follow the course of the outbreak.
Do not test any residents or staff within 1 month of the onset of confirmed COVID-19 illness.
For staff and 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.
Residents may decline testing.
A registered nurse will 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 14 days after the most recent case Positive Date.
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.
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