The facility's quality assurance program completely failed to address the widespread infection control problems. Meeting minutes from June 25 and July 23 showed no documentation that administrators identified quality deficiencies, performed root cause analysis, or developed corrective action plans related to the COVID-19 outbreak.
Inspectors also discovered unsafe and unsanitary handling of residents' contaminated personal laundry throughout the facility.
The Administrator admitted during an interview on August 20 that "the facility had some areas of improvement to address regarding infection prevention and control practices."
But the problems ran deeper than acknowledgment. The facility's governing body failed to ensure COVID-positive employees were excluded from work for the isolation time frame recommended by the Centers for Disease Control. Staff continued working while potentially spreading the virus to vulnerable residents.
The laundry violations compounded the infection risks. Inspectors found widespread problems with unsafe storing and processing of residents' contaminated and potentially hazardous personal laundry. The facility had no proper system for handling soiled items that could harbor infectious material.
Quality assurance meeting minutes revealed no root cause analysis addressing repeated deficiencies related to abuse at the facility. The program designed to identify and fix problems had documented nothing about the ongoing issues.
Federal inspectors issued an immediate jeopardy citation, the most serious level of violation indicating conditions that could cause severe harm or death to residents.
The facility scrambled to implement corrective measures only after inspectors arrived. On August 20, the Administrator and Director of Nursing Services received emergency education on infection control policies, COVID-19 guidelines, transmission-based precautions, and proper handling of soiled linen.
Staff education began the same day. All employees on duty received training on isolation precautions, hand hygiene, enhanced barrier precautions, and COVID-19 testing guidelines. The facility announced employees would not be allowed to work until completing this training.
The Administrator committed to monitoring schedules to ensure no employee worked without proper education.
Rocky Top Care adopted a new policy titled "Handling Soiled Linen" on August 21, just one day before the inspection concluded. An emergency quality assurance meeting that day approved the policy. The Administrator, Director of Nursing Services, Medical Director, and Regional Director of Clinical Operations attended.
The facility also contracted with a commercial laundry service on August 20 to handle personal laundry twice per week. Under the new arrangement, contaminated laundry would be removed from resident areas in bags and placed in labeled bins for pickup. Clean laundry would return in lined bins, folded and covered with protective sheeting.
Housekeeping services would sort and deliver returned laundry to residents.
New COVID-19 protocols established different return-to-work criteria based on employee symptoms and test results. Asymptomatic healthcare providers who were not immunocompromised could return after at least seven days from their first positive test, provided they obtained a negative test within 48 hours of returning to work.
Employees with mild to moderate illness faced stricter requirements. They needed at least seven days since symptoms first appeared, a negative test within 48 hours of return, at least 24 hours without fever while not taking fever-reducing medications, and improvement in symptoms like cough or shortness of breath.
The facility implemented twice-weekly testing for all current employees during the COVID outbreak. Staff with any symptoms including runny nose, cough, sneezing, or shortness of breath would receive additional testing as needed.
If an employee tested positive while at work, they would immediately notify the Administrator, Director of Nursing Services, or Assistant Director of Nursing Services and be sent home to follow CDC isolation guidelines.
Rocky Top Care developed contingency plans for potential staffing shortages during the outbreak. The facility would call all off-duty staff including cross-trained employees, offer incentives and shift swaps, provide bonus days off, arrange split shifts, and call licensed administrative staff to work in any capacity.
If those measures failed, corporate regional support teams would provide additional guidance.
An emergency quality assurance meeting on August 21 brought together the Administrator, Director of Nursing Services, Director of Clinical Operations, Infection Preventionist, Minimum Data Set Coordinator, Director of Care Coordination, and Medical Director. They discussed the deficient practices identified during the federal inspection.
The meeting addressed infection control failures and guidance to prevent COVID-19 spread to staff and residents. Participants also reviewed infection control concerns with handling residents' personal laundry.
Environmental rounds began August 21, with the Administrator and Director of Nursing Services conducting audits using new tools focused on proper handling of soiled linens. No issues were identified during these initial rounds.
The facility committed to continuing all corrective actions until developing a formal Plan of Correction for federal regulators.
The immediate jeopardy citation affected many residents at Rocky Top Care Center. The seven-week COVID outbreak coincided with fundamental breakdowns in infection control that federal inspectors determined created conditions threatening resident safety.
The timing of the facility's response raised questions about its commitment to resident protection. Major policy changes, staff education, and system overhauls occurred only after federal inspectors arrived and identified immediate jeopardy conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rocky Top Care Center from 2024-08-22 including all violations, facility responses, and corrective action plans.