HospitalInspections.org

Based on observation, interview and record review it was determined the facility failed to monitor compliance of their policies regarding 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 Services 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.

In addition, the facility failed to maintain monitoring or surveillance for the required evaluation for Infectious Tuberculosis for the Contract Dialysis Services Staff that had been hired to work in the Dialysis Unit.

The findings include:

Review of the hospital policy relating to Medical Screening on 10/20/10 revealed "1. Testing and screening procedures are conducted in accordance with current CDC recommendations. 2. Frequency of testing is: *Previous undocumented positive TST result...Two -step baseline TST's.

Interview with the Department Services Manager at a local Dialysis Service on 10/20/10 at 9:00am revealed he/she had taken the word of the Contract Employee who reported a previous positive TST on hire on 9/2/10, however the Department Service Manager had failed to obtain the employee documentation to reflect this. The Manager also revealed he/she always completes a chest x-ray if the employee states they have had a past 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 RN Accreditation Manager at Norton Hospitals' on 10/21/10 at 10:00am revealed she was responsible for validating the contract records, and stated he/she receives them from the Contract Company. He/she revealed she checks to make sure the information is there, however does not check for or review the content of the information. The Accreditation Manager also revealed the responsibility lies with the contract company to comply with the facility policy and indicated that the contract employee does not have access to the Pixus Medication System until the paper work has cleared.

Further interview with the Infection Control Director on 10/20/10/ at 9:00am revealed there had been twelve (12) exposed patients at Norton Hospital Downtown, twelve (12) exposures at Norton Audubon Hospital, and eighteen (18) exposures to Norton Surburban Hospital and two (2 ) exposures at Norton Brownsboro Hospital identified as having had contact with the Contract Dialysis Nurse. Of the fourty-four (44) identified dialysis Patients, eight (8) had expired.

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 undocmented 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).