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Based on interview, record review, and facility policy review, the facility failed to maintain an acceptable Infection Control program as evidenced by the failure to test four (4) of one hundred forty-four (144) employees that were exposed to a patient that tested positive for Tuberculosis Mycobacterium. Patient #1 had admissions to the facility on 04/03-06/19 and 04/17-23/19 and was tested for Tuberculosis (TB) via an Acid Fast Bacillus (AFB) culture on 04/04/19. On 05/03/19, a positive AFB culture was received on Patient #1; however, the facility failed to ensure all staff with exposure to the patient were tested for TB per facility policy.

The findings include:

Review of the facility's policy entitled "Mycobacterium Tuberculosis Testing of Baptist Healthcare Workers," dated 08/31/16, revealed that following the report of an occupational TB exposure every effort will be made to determine the healthcare worker's risk for TB acquisition as a result of the potential exposure. According to the policy, the healthcare worker will be tested upon notification of the exposure and again at eight to ten weeks post-exposure.

Observations on the medical/surgical 300 Unit on 11/05/19 at 4:26 PM revealed two (2) patient rooms with signs posted outside the door notifying staff and visitors of precautions, and personal protective equipment in place for use. Observations on the medical/surgical 400 Unit on 11/05/19 at 4:33 PM revealed seven (7) patient rooms with signs posted outside the door notifying staff and visitors of precautions, and personal protective equipment in place for use.

Interview with the Infection Control Director on 11/05/19 at 3:34 PM revealed Patient #1 had a thoracentesis done on 04/04/19 with pleural fluid sent for an Acid Fast Bacillus (AFB) culture. Further interview revealed that the initial AFB stain revealed no acid-fast bacilli seen on direct smear; however, on 05/03/19 the facility received an updated report of the AFB culture with Acid Fast Bacilli isolated. Further interview revealed the facility received a preliminary report on 05/04/19 with the results revealing Mycobacterium tuberculosis complex identified by a DNA probe. According to the interview, the local Health Department was notified of the results of the AFB culture on 05/06/19.

Review of the discharge summary for Patient #1 revealed the patient had a hospital stay from 04/03/19 to 04/06/19 with diagnoses that included Pleural Effusion on the right side, Lactic Acidosis, Elevated Diaphragm, Type 2 Diabetes Mellitus with Stage 3 Chronic Kidney Disease, Hypertension, and Hyperlipidemia. Review of the History and Physical revealed that Patient #1 had recently been diagnosed with Influenza and Upper Respiratory Infection. Further review of the discharge summary revealed the patient had a CT scan that showed a moderate to large right pleural effusion. A thoracentesis procedure was done with the pleural fluid showing lymphocytic but acid-fast bacilli stain was negative. Further review of the discharge summary revealed Patient #1 was feeling much better after the thoracentesis with complete resolution of the patient's shortness of breath and hypoxia.

Review of the discharge summary for Patient #1 revealed the patient had a readmission to the hospital on 04/17/19 to 04/23/19 with diagnoses that included Right-sided Pleural Effusion lymphocytic and exudative, Fibrotic Changes with volume loss on the left lung, Chronic Kidney Disease Stage 3 to 4, Acute Hyponatremia, Hyperlipidemia, Diabetes Mellitus Type 2, Systemic Hypertension, Mild Lactic Acidosis, Positive D-Dimer, Dyspnea improved with oxygen supplementation, Chronic Elevation of the Right Hemidiaphragm, and Hypoxia. According to the discharge summary, the patient presented to the hospital with significant weakness, and shortness of breath. Patient # 1 underwent a thoracentesis, which showed lymphocytic exudate on the right side. Further review of the discharge summary revealed the patient declined to have a chest tube to alleviate the effusion and the patient is a poor candidate for extensive thoracic intervention.

Review of the Infectious Disease Contact Studies dated 05/06/19 revealed the department managers were notified of the positive AFB culture for Patient #1 and instructed to investigate and provide a list of healthcare workers associated with the patient during the exposure period. According to the document, the department managers were to provide a list of the healthcare workers to the Employee Health Department.

Interview with the Director of Employee Health on 11/05/19 at 4:04 PM revealed the facility notified the local Health Department regarding the exposure and the Health Department provided guidance on the exposure risk. According to the interview, the Health Department stated that healthcare workers with eight (8) hours or more in a week exposed to Patient #1 were considered High Risk and the healthcare workers with less than eight (8) hours a week were considered Low Risk. Further interview with the Director of Employee Health revealed the Manager of Employee Health at Baptist Health that provided oversight of the exposure investigation for Patient #1 was deployed to active duty on 10/25/19 and not available for interview. The interview revealed the Director of Employee Health was not aware there was an issue with the follow-up testing for the employees.

Interview with the Director of Employee Health on 11/07/19 at 9:19 AM revealed the facility had a total of one hundred forty-four (144) employees that were exposed to Patient #1 during the two (2) hospital stays. Further interview with the Director of Employee Health revealed four (4) employees in the High Risk exposure group had not completed the mandatory tuberculosis testing. According to the interview, the four (4) employees that were identified had a blood test for tuberculosis performed on 11/06/19. Further interview with the Director of Employee Health on 11/07/19 at 9:19 AM revealed the Manager of Employee Health should have followed up on the list of employees at the end of the post-exposure period to ensure all employees were tested.