HospitalInspections.org

Based on observation, interview and record review it was determined the facility failed to monitor compliance of their policies regarding the infection control program requirements, based on the facility failure to follow guidelines related to Positive Tuberculin Skin Testing (TST) with no documentation. The facility employed a Contract Dialysis Nurse from a local Dialysis Service with no documentation of a reported history of having a positive TST as per regulatory requirement. The Contract Nurse subsequently developed active Tuberculosis while working at the facility.

The findings include:

Review of the hospital policy relating to the Tuberculin Skin Testing Program on 10/20/10 revealed under " a.1.All hospital employees- At the time of employment, all new employees will be given a TB skin test, unless they can document a previous positive TST".

Interview with the Department Service Manager at a local Dialysis Service on 10/20/10 at 9:00am revealed she had taken the word of the Contract Employee who reported a previous positive TST on hire on 9/21/10; however, the Department Service Manager had failed to obtain the employee documentation to reflect this. The Manager also revealed he/she always completed a chest x-ray if the employee states they have had a past previous positive TST, and then sends the results to the hospital. The Manager indicated that she was not aware this was the regulation regarding testing and stated their protocol was to complete the Chest x-ray.

Interview with the Liaison to the local Dialysis Contract Service on 10/21/10 at 7:55am revealed they send the completed TST testing or chest x-rays to her and she is responsible for checking to see if the information is there and complete. The Liaison indicated that records are kept there at the facility and the files are reviewed every couple of months at which time she calls the Dialysis Services if any are TST's or chest x-rays are due.

Interview with the Director of Quality and Infection Control on 10/20/10 at 3:30pm revealed there were seven (7) patients who received exposure from the Contract Dialysis Nurse. The Director also stated that two (2) of the patients had expired and two (2) were still in the process of being contacted.

Review of the Morbidity and Mortality Weekly Report (MMWR recommendations and reports 12/30/2005) regarding indications for two-step tuberculin skin test (TSTs) revealed for previous undocumented positive TST result would recommend testing of Two step TST(s). *For newly hired health care workers and other persons who will be testing on a routine basis (e.g.) residents or staff of long term care facilities), ....If the previous positive TST result is not documented, administer two-step TSTs or offer BAMT (Blood Assay for Mycobacterium tuberculosis).