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Based on policy and procedure review, medical record review, staff interviews, an interview with the Tuberculosis Coordinator at the County Health Department, and personnel file review, the facility's infection control staff failed to have a tracking system in place to monitor staff exposure to tuberculosis in 2 of 2 patients (#7 and #9) reviewed.

Findings include:

Review of the named facility's policy titled "Employee Health Program", last review date 03/10/14, revealed "...The purpose of this program description is to provide guidance to accomplish the following Employee health goals:...G. Detect and manage outbreaks of infections among employees...Communicable Diseases The Employee Health Nurse will evaluate all reported exposures and reported diagnoses of communicable illnesses as appropriate...". Review of the facility's policy titled "TB (Tuberculosis -a potentially serious infectious disease that mainly affects the lungs. The bacteria that cause tuberculosis are spread from one person to another through tiny droplets released into the air via coughs and sneezes) Exposure Control Plan, last review date 02/20/13, revealed "...The purpose of the policy is to provide guidelines that will achieve early detection, isolation, and treatment of persons with active TB in order to minimize the risk of TB transmission in hospital settings...Investigating contacts of persons with TB...when a patient is seen in the institution without being recognized as having TB and promptly isolated, but is subsequently diagnosed as having infections TB: a. Identify HCWs (Health Care Workers) and other patients who were exposed to the patient...Administer a TST (Tuberculosis Skin Test) to all HCWs and patients with documented exposure as soon as possible after the exposure. If initial test is negative, a second test should be administered 8 - 10 weeks after the exposure was terminated.

1. Closed medical record revealed a 35 year old Hispanic female patient (Patient #9), post recent relocation to the United States from Honduras, admitted on 12/06/2014 with acute respiratory failure (a condition where not enough oxygen passes through the lungs to the blood, or the lungs cannot properly remove carbon dioxide (a waste gas) from the blood), Pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid) and Cavitary lung disease (a disease in which the normal lung architecture is replaced by a cavity (a gas-filled space within a mass or nodule)) per MD (Medical Doctor) #1's History and Physical (H&P) dated 12/06/2014 at 1310. Further record review revealed Patient #9 reported a positive family history of TB and subsequently tested positive for TB during her 12/06/2014 admission. Patient #9's 12/06/2014 H&P also indicated the patient was hospitalized 09/22/2014-09/26/2014 "...with bilateral (both sides) pneumonia..." and had a return Emergency Department (ED) visit on 10/30/2014. Record review revealed Patient #9 was not tested for TB during her 09/22/2014 admission or during her 10/30/2014 ED visit.

Interview with the facility's Employee Health Nurse (EN #2) and the facility's Infection Preventionist (IP #3 - a person who specializes in preventing infections), on 02/23/2016 at 1430, revealed once Patient #9 tested positive for TB, an investigation was launched to identify staff that had unprotected exposure to Patient #9 during her 09/26/2014 admission, 10/30/2014 ED visit, and her 12/06/2014 admission. IP #3 reported a list was compiled from Patient #9's chart that included all staff members' names that were in the patient's chart. Per IP #3, the facility's department directors where contacted to assess which staff members were exposed to the patient. Review of a facility email, dated 12/12/2014 at 1635, that was sent from IP #3 to the department directors revealed, "We have a patient who is currently inpatient (Patient #9)...testing has confirmed that she has M. tuberculosis. We have placed TST on staff who we have identified as having had unprotected exposure to the patient. This is their baseline testing. ...the same patient had a hospital admission on 9/22-9/26 2014...and an ED visit on 10/30/2014...We have identified the staff that worked with the patient who have documented in the chart. ...I would like you to complete a list of staff that were on the schedule to work those days who may have had contact with this patient...Please send the list to (EN #2) and copy me...". EN #2 stated when there is a TB exposure, "I will send out an email and call to make them (staff) aware they need to come in to get a skin test as they have been exposed." Review of a facility email, dated 12/15/2014 at 1556, that was sent from EN #2 to 51 staff members revealed, "You are receiving this email because you need to see me as soon as possible to get a TB skin test done. Your name came up as having worked with a patient either last week or back near the end of September that has recently been diagnosed with m. tuberculosis. ...Please call to schedule a time to see me for a TST, as soon as you can. Normally I would have to do one back in September and this one would make the 12 week follow up but since we weren't aware of this diagnosis back in September, this will be your only skin test needed...". The facility failed to reveal documentation that indicated which facility staff members, on the 12/15/2014 email from EN #2, had their initial exposure to Patient #9 in September, versus an initial exposure in October or December. If a staff member had an initial TB exposure in December, the December TST would be their baseline. If the December TST resulted as negative, per the facility's policy, a second TST should be placed 8 - 10 weeks after the exposure. Review of a facility email, dated 01/21/2016 at 1724, sent by EN #2 to staff revealed, "...We've had a sero-conversion (a period of time when an antibody becomes positive in the blood) for a staff member that was exposed to a patient being positive for Tuberculosis in October 2014. I am following up with you because you need to be tested in follow-up due to possibly having been exposed in some way to this patient...".

Telephone interview, on 02/24/2016 at 1420, with the TB Coordinator at the County Health Department revealed the standard for testing for TB exposure includes a skin test at the time of exposure and an additional skin test "at the 8 week mark".

Follow-up interview with the EN #2 on 02/24/2016 revealed when there is a TB exposure at the facility EN #2 will administer a "TB skin test (to staff) as soon as possible. I prefer to do a follow-up in 8 to 12 weeks with another skin test." EN #2 was unable to provide evidence of a tracking system that detailed the names of staff members, their date of TB exposure and correlating first TST and follow-up 8 to 12 week TST. EN #1 could not provide any documentation that recorded the compliance rate of staff receipt of the initial TST post exposure or the 8 to 12 week follow-up TST. Further interview revealed, "I have a list that I put a check mark on, but I can't put my hands on it right now." EN #2 said, a "big majority" of the staff had the initial skin test placed and "less than 50 percent" returned for the 8 to 12 week skin test. EN #2 reported, "For the most part, I verbally told them they needed to return in 8 to 12 weeks for a skin test. I did not send a reminder email or call them."

Review of a sample of employee personnel files (chosen from the EHN's 12/15/2014 email), revealed the employees obtained an initial TST in December of 2014. Record review did not reveal administration of a second TST 8-10 weeks after the initial TST resulted as negative.

2. Closed medical record review revealed a 36 year old female patient (Patient #7) admitted on 03/17/2015 with Sepsis (a potentially life-threatening complication of an infection), Cavitary lesion of lung, Fever, Septic pulmonary embolism (the passage of infectious particles into the lungs), Infective endocarditis (an inflammation of the inner tissues of the heart), IV (intravenous - directly into a vein) drug use, according to MD #4's H&P dated 03/17/2015 at 1646. Further record review revealed Patient #7 was transferred on 03/18/2015 at 1422 to another facility for "treatment by critical care MD Infectious disease specialist...". Patient #7's Transfer Form revealed "...TB test placed on right forearm 3/17/15...". According to the Centers for Disease Control and Preventions, "The skin test reaction should be read between 48 and 72 hours after administration." Patient #7's TST was not read prior to her transfer from the named facility.

Interview with IP #3 on 02/24/2016 at 1525 revealed, "We don't follow-up if a patient is transferred after a skin test is placed."

NC00114131