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Based on record reviews and staff interviews, it was determined the facility failed to follow its' own policies regarding reporting communicable diseases to public health authorities for one patient (#1) in the selected sample of two, who within the past year, contacted a communicable disease the facility should have reported. Findings include:

Review of the hospital infection control policy #1200-003.3, revealed the infection control coordinator or designee was responsible for complying with 902 KAR 2:020 in reporting infectious diseases.

Record review revealed Patient #1 was admitted to the hospital, on 07/17/10, with complaints of shortness of air, fever and weakness. Laboratory studies included a sputum acid fast bacilli (AFB) with smear obtained on 07/21/10 and sent to an outside laboratory. This was reported as positive for TB and a typed note from the lab report documented this was reported to the hospital on 07/23/10. Medical record documentation revealed the patient was placed in respiratory isolation and treated with TB sensitive antibiotics. Patient #1 expired on 07/27/10.

An interview with the Director of Nursing, on 10/22/10 at approximately 1:55 PM, revealed the hospital had been in contact with the local health department when Patient #1 tested positive for TB. However, the facility could not provide documented evidence of this or that a EPID 200 (the form used to notify the state of reportable diseases) was completed. On the day of the survey, the hospital obtained faxed information from the state TB Prevention and Control Program. This information documented that on 08/02/10 the local health department was informed Patient #1 was TB positive. State regulations at 902 KAR 2:020 requires health professionals to report TB to the local health department or public health officials within one (1) business day. Although the hospital first became aware Patient #1 had positive cultures for TB on 07/23/10, reporting on 08/02/10 represented a time frame of six (6) business days before this was reported.