Located in Blair, Nebraska, Good Shepherd Lutheran Home (GSL) has that small, hometown feel, yet is only 20 miles away from Omaha, the largest metropolitan city in Nebraska. Its daily resident census throughout the COVID-19 pandemic has ranged from 50 to 55. In August 2022, GSL had a sudden COVID-19 outbreak in which 21 of 54 residents or 38%, and 19 staff members or 20%, tested positive.

“We had been doing so well at keeping our residents safe from COVID-19. We needed to determine what went wrong,” said GSL Infection Preventionist Mary Powell, MBA, MSN, RN.

Prior to August, GSL had effectively prevented massive COVID-19 outbreaks in its resident population, with zero residents testing positive in 2020, seven testing positive in 2021 and four testing positive in 2022 through July. The GSL leadership team proactively responded at the onset of the pandemic in March 2020 by providing education and hands-on training to staff related to infection control practices. Leadership placed increased emphasis on practicing hand hygiene and correctly donning and doffing personal protective equipment (PPE). This training was often provided on a weekly or biweekly basis to keep pace with changing regulations.

GSL loaded on-demand videos about hand hygiene and donning/doffing PPE on the computers at each nursing station to allow staff easy access whenever needed. This made the training easily accessible to any employee that needed a refresher. Staffing agency personnel were required to watch the training videos and to sign off on the training. All staff were required to provide return demonstrations of several processes as a means of competency testing and identifying any additional training needs.

Powell said they also placed emphasis on educating board members, residents and their family members, vendors and other potential visitors. GSL provided education to assisted living staff and residents, and to the residents in independent living areas, as all buildings are connected.

GSL worked closely with its local public health department, the Nebraska State Department of Health and Human Services, the University of Nebraska’s Infection Control Assessment and Promotion (ICAP) program, the local health care coalition and the Washington County Emergency Management Manager.

In addition, “Our TMF quality improvement specialist provided our facility with the 5 Whys Tool (PDF). We used this to help us drill down and determine the root cause of our August outbreak,” Powell said. The possible causes of the outbreak included:

• Visitor non-compliance (e.g., visiting when positive for COVID-19 within 14 days; not answering screening questions accurately; visiting if recently exposed to COVID-19; not wearing a mask in residents’ rooms; not closing a door when visiting in a room with mask off)
• Resident non-compliance with wearing masks when out of their room; not closing the door when visiting in the room with masks off; attending community social events without masking or social distancing
• Having an old ventilation system with no available funding for upgrades
• Having shared bathrooms between two resident rooms
• Hand sanitizer dispensers requiring frequent pumps to distribute product

GSL determined that the possible initial cause of the outbreak was the result of a visitor not accurately disclosing their COVID-19 positive status prior to visiting, and being in the resident room unmasked.

Immediately leadership sent a letter to all GSL residents and their families explaining that there were several residents in the facility who had tested positive for COVID-19. In the letter, leadership reinforced the importance of accurate screening, practicing hand hygiene, and not visiting with residents if they had a recent COVID-19 diagnosis or had been exposed to someone who had recently tested positive for COVID-19.

“We realized the importance of having all departments — nursing, fiscal, dietary, housekeeping, laundry, maintenance, therapy, social services — represented and actively involved as we planned our strategies and processes. We knew that COVID-19 could impact all aspects of our operations,” said Powell, “so our quality improvement team was multidisciplinary.”

GSL updated its screening document to include a very specific question: Has the visitor tested positive for COVID-19 in the past 14 days? “We developed a teaching document for residents and visitors, discussing ways to help prevent the spread of COVID-19,” Powell said.

In early September 2022, GSL sent a letter out to family members, emphasizing COVID-19 guidance and visitation related to exposure or a positive test in the previous 14 days. “We stressed that individuals with no symptoms may still spread COVID-19 to loved ones,” said Powell. “We reinforced not visiting if sick, if there was a recent exposure, or if they tested positive in 14 days.”

“[The] TMF QIN-QIO was instrumental in providing real-time resources and clarification of regulatory information, as a way of helping us navigate the challenges caused by the pandemic,” Powell said. TMF worked closely with the ICAP program, presents weekly COVID-19 and infection control webinars, and helps facilities navigate the many changes in National Healthcare Safety Network (NHSN) reporting.

Refresher training (e.g., hand hygiene, donning and doffing PPE, use of face masks, how to prevent COVID-19) was provided again to all GSL staff in early September 2022. GSL installed new hand sanitizer dispensers and hand sanitizer product throughout the facility. In October 2022, they changed the air filters in each resident room, and will change them at least every six months or more frequently, if needed.

Some of GSL’s key ongoing practices include:

• Training, education and competency testing related to infection control
• Ensuring sufficient supply of PPE
• Developing and implementing policies specific to COVID-19
• Establishing a designated COVID-19 wing, used early in the pandemic for residents with symptoms
• Focusing on vaccination of residents and staff
• Providing education to residents, their family, visitors and vendors
• Testing any resident, staff and contract worker with symptoms for COVID-19 (early in the pandemic, all tests were PCR; when the rapid point-of-care [POC] test kits became available, GSL followed up with a PCR test for anyone with symptoms, regardless of what the POC test showed)
• Continually requiring staff to wear facemasks (e.g., surgical or N-95), regardless of lessening of restrictions

As of Nov. 6, 2022, GSL’s COVID-19 vaccination numbers were:

• 100% of resident population fully vaccinated against COVID-19; 96% up to date with bivalent vaccine
• 90% of employees fully vaccinated against COVID-19; 14% up to date with bivalent vaccine (7 employees have vaccine exemptions)

“We learned the importance of acting quickly in an ever-changing regulatory and pandemic environment, and listening to the staff’s ideas, thoughts and frustrations,” Powell recalls. “We learned the importance of developing plans of action, putting them in place, and continually monitoring for compliance. Vaccinations do make a difference!”

“Throughout the pandemic, facilities often just hear about what they are doing wrong,” Powell said. “Our TMF quality improvement specialist became a strong cheerleader for our facility and really helped focus on what we were doing right, not just areas for improvement. She reviewed our processes and provided reinforcement that we were on the right track, and that we had great systems in place to help protect residents and staff from COVID-19.”

Powell said that GSL learned the most important thing to do is educate everybody repeatedly. It is important to provide continuous and just-in-time training not just to staff, but to residents, their family members, visitors and vendors.

“Being informed helps facilitate compliance,” said Powell. “We will continue to educate, answer questions, explain outcomes, build on successes, learn from challenges and provide rationales for why we do what we do.”