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Based on interview and record review, the facility failed to provide timely treatment and services for two (#11 and #12) of three sampled patients reviewed with positive Tuberculosis Bacillus (TB) test results, from a total sample of 13 patients. This resulted in the failure of the facility to maintain compliance with infection control program requirements resulting in the potential for increased risk of TB exposure for all patients. In addition the facility failed to maintain 1 of 2 blood glucose monitors (Glucometers) in clean condition and to train 1 of 2 staff nurses in the facility's procedure for cleansing Glucometers, resulting in the potential for increased risk of infection for all patients who are tested using the glucometer. Findings include:
Patient #11
On 02/10/2015 at 1330, a review of clinical records for patient #11 on the east one admission unit revealed that patient #11 was admitted into the facility on 11/17/14 with the status of being incompetent to stand trial. According to the Infection Control Coordinator, a PPD (purified protein derivative [Tuberculosis skin test for infection]) skin test is performed on all newly admitted patients. The skin test is a method used to diagnose latent tuberculosis.
Progress notes revealed the following:
On 11/19/14 "PPD skin test positive, red in color, induration 20 mm (large reaction), voice mail infection control. Note left for medical doctor to f/u (follow up)."
On 11/20/14 "Per patient's psychiatrist, there will be no quarantine for patient until further data is gathered for patient's TB status."
Review of lab results on 02/10/15 at 1335 revealed that a Quantiferon-TB Gold In-Tube test (QFT-GIT) was drawn on 11/21/14 and the results dated 11/28/14 revealed a positive test result. According to the Centers for Disease Control, a positive QTF-GIT indicates that a person has been infected with TB bacteria.
Further review of the clinical record revealed that a chest x-ray was ordered for patient #11 on 12/4/14, which was conducted on 12/5/14 and resulted in a "normal chest x-ray" result.
The Medication Administration Record (MAR) was reviewed on 2/10/15 at 1345 which revealed that patient #11 began treatment with Isoniazid 300 milligrams daily and Pyridoxine (Vitamin B6) on 12/9/2014. The patient was to continue on the medication for a period of nine months.
The nursing staff was queried about the delay in the initiation of treatment for the patient, and was unable to explain the reason for the delay.
Patient#12
At 1408 on 02/10/15 clinical records were reviewed for patient #12 on the east 2 unit. According to the clinical record, patient #12 had been exposed to TB at the time of admission into the facility on 07/24/14. Patient #12 also had a diagnosis of Hepatitis C.
A Quantiferon-TB Gold In-Tube test was drawn on 8/5/14 and the results revealed a "positive" test result. A chest x-ray was conducted on 08/18/14 for the patient. Patient #12 was started on pyridoxine on 08/6/14 and Isoniazid 300 mg on 8/26/14. It was unclear why the facility took one month before beginning the TB treatment for the patient. Unit staff reported that the patient resided in a private room at the present time and at the time of diagnosis.
On 02/11/2015 at 0900, Staff B stated that the patient was asymptomatic, and that was the reason for the delay in treatment.
An interview was conducted with the Infection Control Coordinator (ICC) on 02/11/2015 at 1030 who explained that she was aware of the positive test result for patient #12, so she contacted the local health department and offered recommendations to the physician regarding the necessary treatment options and services for Patient #12, however, the ICC reported that the physicians do not always honor the recommendations of the nurses.
The ICC verified that the above patients should have been treated in a more timely manner.


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On 2/10/15 at 1045, during a tour of the 1 South Unit, the unit's Glucometer was observed to have a small amount of white-tan residue on the front side. This observation was confirmed by Nurse D. Nurse D was asked how the Glucometer is supposed to be cleaned. Nurse D responded: "with soap and water...the procedure is alcohol swabs or wipes...with a germicidal wipe."

On 2/11/15 at approximately 1100 the facility's policy for cleansing Glucometers was reviewed with staff F. The "Assure Platinum Assurance Program," dated 5/14, included a "Nursing Skills" training in cleansing Glucometers that requires nurses to demonstrate: "care of glucometer- wipe with disinfectant detergent or germicidal wipe." On 2/11/15 at approximately 1100 staff F confirmed that the type of "disinfectant soap" to be used was not specified in this procedure and that alcohol wipes are not included in the training procedure.