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Based on a review of facility documents and staff interviews, it was determined that the governing body of the facility failed to ensure the safety of patients at the hospital. The facility policy for annual screening of employee health failed to include important guidance for the surveillance and control of tuberculosis (TB). An employee demonstrated signs and symptoms of possible active TB during an annual health screening (the employee was later confirmed to have contagious TB), yet the employee was allowed to return to work. As of the exit date of the survey (9/15/14), a large (yet undetermined) number of patients and visitors had been exposed to TB by this employee, including newborn infants.


Findings were:


A report was received by the Texas Department of State Health Services (DSHS)-Health Facility Compliance unit from the DSHS Director of Infectious Disease Prevention Section, which indicated that a direct patient care employee (staff #1) working at the hospital tested positive for active TB. Staff #1 reported being symptomatic since December 2013, and Staff #1 reported coughing and hemoptysis (coughing up blood) during an annual TB screening in July 2014.

The Centers for Disease Control and Prevention (CDC), identified the following regarding TB, "The TB bacteria are put into the air when a person with TB disease of the lungs or throat coughs, sneezes, speaks, or sings. People nearby may breathe in these bacteria and become infected." The CDC also identified the following regarding TB, "Symptoms of TB disease include: ...a bad cough that lasts 3 weeks or longer...weakness or fatigue." Referenced on 9/15/2014 from the CDC .


During the onsite investigation on 9/9/14, the following information was obtained from the facility's Occupational Health Nurse, Risk Manager and staff #5 (Infection Control Personnel) during an interview on the same date, which revealed the following timeline:

- Over 10 years ago, staff #1 had both a positive TB skin test and subsequent chest x-ray, which indicated latent TB.

- Around December 2013, staff #1 had not been feeling well and was exhibiting general non-descript symptoms (including a productive cough and fatigue). During this time, and for the period following, staff #1 worked on the Post-Partum (PP) unit.

- 7/2/14, annual employee health screening by the facility's Occupational Health Nurse revealed that staff #1 had a base-line chest x-ray after a positive TB skin test, and that staff #1 presented with a productive cough and fatigue at the time of the screening. The Occupational Health Nurse was informed by staff #1 during the screening that staff #1 was being evaluated by a personal physician for the productive cough and fatigue, and no definitive diagnosis had been determined.

- 8/15/14, last day staff #1 worked at the facility...demonstrated by a document provided to the surveyor called "iSeries Timekeeper...EMPLOYEE TIME CARD". Staff # 1 continued to have respiratory symptoms and fatigue while providing direct care to newborns up to this date.

- 8/21/14, staff #1 demonstrated positive TB test results at the office of her private physician. Shortly after this, staff #1 had informed the hospital that they had active TB, and staff #1 had not returned to work, making 8/15/14 the last day worked.

- 9/4/14, by this date the hospital had begun coordinating with the local health department to develop an exposure plan. On 9/4/14, hospital administration, along with representatives from the local health department (a nurse and a physician), met with most of the current staff of the PP unit and the staff were screened for symptoms of active TB, and staff were encouraged to have a test for TB (quantiferon gold - QFG) provided by the hospital. The following documents were provided to the surveyor on 9/9/14: a roster signed by most of the PP unit staff which documented attendance of the 9/4/14 meeting; a flow-sheet which demonstrated that most of the current PP unit staff had received the QFG test, most of the results had yet to come back.


Facility policy, Annual Employee Physical Assessments (Policy #806, Original Date: 03/2007, Revised Date: 10/2010, and reviewed by the surveyor on 9/9/14), included the following regarding TB surveillance: "Sierra Providence Health Network (SPHN) requires all employees to complete an annual physical assessment by the facility's Occupational Health Nurse (OHN) to include:...4. An annual tuberculine skin test (PPD) or written documentation of a previously positive tuberculin skin test, followed up by a chest x-ray (CXR) and/or referral to the health department as appropriate."

Facility policy, Tuberculosis Exposure Plan (Policy #3, Original Date: 1/03, Review/Revised Date: 1/05; 4/07, and reviewed by the surveyor on 9/9/14), included the following regarding TB surveillance: "8 ...A. Occupational Health Department will provide employees assessments. Upon hire two step TST (tuberculin skin test) testing is conducted ...J. Personnel with a positive TST: 1. Answer the Tuberculosis risk questionnaire. 2. An x-ray is taken as a baseline reference and referred to the City County Health Department for evaluation and clearance. 3. The City County Health Department, Tuberculosis department evaluates positive findings and recommendations followed. 4. X-rays are recommended once at baseline and when clinical presentation suggests the activation of latent tuberculosis."


The facility policy, Annual Employee Physical Assessments, failed to include all of the guidance regarding TB surveillance that is found in the facility policy Tuberculosis Exposure Plan. Specifically, the policy did not include all of the guidance for employees with a positive tuberculin skin test..."X-rays are recommended once at baseline and when clinical presentation suggests the activation of latent tuberculosis." The facility's Occupational Health Nurse had access to information which indicated that staff #1 had a baseline chest x-ray after a positive TB skin test, and staff #1 had a cough and fatigue during the annual screening, which are clinical presentations that suggest activation of latent TB. The Annual Employee Physical Assessments policy did not indicate a need for further TB evaluation, and the Occupational Health Nurse did not pursue further TB evaluation of staff #1.


A conference call was held on the afternoon of September 15, 2014; in attendance were the Health Facility Compliance Zone 1 Manager (complaint surveyor) and Branch Manager, and the facility's Director of Infection Prevention and Occupational Health Services, Chief Nursing Officer (CNO), Chief Medical Officer (CMO), and Director of Quality.

During this call, the facility administration confirmed that staff #1 had presented with a productive cough during the July employee health screening, and staff #1 had presented with similar symptoms for months prior to July, possibly as far back at December 2013.

The administration also confirmed that staff #1 was diagnosed with contagious TB on 8/21/14, staff #1 had cared for infant patients (feeding and bathing) with present respiratory symptoms since at least July 2014. An undetermined number of infants have possibly been exposed to TB while receiving care at the facility. The facility was working with the local health department on developing a plan to identify and notify potentially exposed patients.

The CNO said that she and the Director of Post-Partum had met with staff #1 on several occasions between 7/2/14 and 8/15/14 (last day worked), and staff #1 did not exhibit any signs of a cough during these meetings. The CNO also said that prior to 8/21/14, facility administration attributed staff #1's symptoms to allergies.

The CMO highlighted that staff #1 had been under the care of a private physician for the respiratory symptoms during the time of the employee health screening of staff #1 on 7/2/14, at which time the Occupational Health Nurse was made aware.

Based on a review of facility documents and staff interviews, it was determined that the facility failed to protect the right of patient's to receive care in a safe setting. An employee of the facility with contagious tuberculosis provided direct patient care to a large, but unknown, number of newborns.


Findings were:


The facility policy for annual screening of employee health failed to include important guidance for the surveillance of tuberculosis (TB). An employee demonstrated signs and symptoms of possible active TB during an annual health screening (the employee was later confirmed to have contagious TB), yet the employee was allowed to return to work where the employee provided direct care to newborns. Cross refer tag A-0144.

Based on a review of facility documents and staff interviews, it was determined that the facility failed to provide a safe care environment, regarding infection control for all patients recieving care at the hospital. The facility policy for annual screening of employee health failed to include important guidance for the surveillance of tuberculosis (TB). An employee demonstrated signs and symptoms of possible active TB during an annual health screening (the employee was later confirmed to have contagious TB), yet the employee was allowed to return to work. As of the exit date of the survey (9/15/14), an undetermined number of patients had been exposed to TB by this employee, including newborn infants.


Findings were:


A report was received by the Texas Department of State Health Services (DSHS)-Health Facility Compliance unit from the DSHS Director of Infectious Disease Prevention Section, which indicated that a direct patient care employee (staff #1) working at the hospital tested positive for active TB. Staff #1 reported being symptomatic since December 2013, and Staff #1 reported coughing and hemoptysis (coughing up blood) during an annual TB screening in July 2014.

The Centers for Disease Control and Prevention (CDC), identified the following regarding TB, "The TB bacteria are put into the air when a person with TB disease of the lungs or throat coughs, sneezes, speaks, or sings. People nearby may breathe in these bacteria and become infected." The CDC also identified the following regarding TB, "Symptoms of TB disease include: ...a bad cough that lasts 3 weeks or longer...weakness or fatigue." Referenced on 9/15/2014 from the CDC .


During the onsite investigation on 9/9/14, the following information was obtained from the facility's Occupational Health Nurse, Risk Manager and staff #5 (Infection Control Personnel) during an interview on the same date, which revealed the following timeline:

- Over 10 years ago, staff #1 had both a positive TB skin test and subsequent chest x-ray, which indicated latent TB.

- Around December 2013, staff #1 had not been feeling well and was exhibiting general non-descript symptoms (including a productive cough and fatigue). During this time, and for the period following, staff #1 worked on the Post-Partum (PP) unit.

- 7/2/14, annual employee health screening by the facility's Occupational Health Nurse revealed that staff #1 had a base-line chest x-ray after a positive TB skin test, and that staff #1 presented with a productive cough and fatigue at the time of the screening. The Occupational Health Nurse was informed by staff #1 during the screening that staff #1 was being evaluated by a personal physician for the productive cough and fatigue, and no definitive diagnosis had been determined.

- 8/15/14, last day staff #1 worked at the facility...demonstrated by a document provided to the surveyor called "iSeries Timekeeper...EMPLOYEE TIME CARD". Staff # 1 continued to have respiratory symptoms and fatigue while providing direct care to newborns up to this date.

- 8/21/14, staff #1 demonstrated positive TB test results at the office of her private physician. Shortly after this, staff #1 had informed the hospital that they had active TB, and staff #1 had not returned to work, making 8/15/14 the last day worked.

- 9/4/14, by this date the hospital had begun coordinating with the local health department to develop an exposure plan. On 9/4/14 hospital administration, along with representatives from the local health department (a nurse and a physician), met with most of the current staff of the PP unit and the staff were screened for symptoms of active TB, and staff were encouraged to have a test for TB (quantiferon gold - QFG) provided by the hospital. The following documents were provided to the surveyor on 9/9/14: a roster signed by most of the PP unit staff which documented attendance of the 9/4/14 meeting; a flow-sheet which demonstrated that most of the current PP unit staff had received the QFG test, most of the results had yet to come back.


Facility policy, Annual Employee Physical Assessments (Policy #806, Original Date: 03/2007, Revised Date: 10/2010, and reviewed by the surveyor on 9/9/14), included the following regarding TB surveillance: "Sierra Providence Health Network (SPHN) requires all employees to complete an annual physical assessment by the facility's Occupational Health Nurse (OHN) to include:...4. An annual tuberculine skin test (PPD) or written documentation of a previously positive tuberculin skin test, followed up by a chest x-ray (CXR) and/or referral to the health department as appropriate."

Facility policy, Tuberculosis Exposure Plan (Policy #3, Original Date: 1/03, Review/Revised Date: 1/05; 4/07, and reviewed by the surveyor on 9/9/14), included the following regarding TB surveillance: "8 ...A. Occupational Health Department will provide employees assessments. Upon hire two step TST (tuberculin skin test) testing is conducted ...J. Personnel with a positive TST: 1. Answer the Tuberculosis risk questionnaire. 2. An x-ray is taken as a baseline reference and referred to the City County Health Department for evaluation and clearance. 3. The City County Health Department, Tuberculosis department evaluates positive findings and recommendations followed. 4. X-rays are recommended once at baseline and when clinical presentation suggests the activation of latent tuberculosis."


The facility policy, Annual Employee Physical Assessments, failed to include all of the guidance regarding TB surveillance that is found in the facility policy Tuberculosis Exposure Plan. Specifically, the policy did not include all of the guidance for employees with a positive tuberculin skin test..."X-rays are recommended once at baseline and when clinical presentation suggests the activation of latent tuberculosis." The facility's Occupational Health Nurse had access to information which indicated that staff #1 had a baseline chest x-ray after a positive TB skin test, and staff #1 had a cough and fatigue during the annual screening, which are clinical presentations that suggest activation of latent TB. The Annual Employee Physical Assessments policy did not indicate a need for further TB evaluation, and the Occupational Health Nurse did not pursue further TB evaluation of staff #1.


A conference call was held on the afternoon of September 15th, 2014; in attendance were the Health Facility Compliance Zone 1 Manager (complaint surveyor) and Branch Manager, and the facility's Director of Infection Prevention and Occupational Health Services, Chief Nursing Officer (CNO), Chief Medical Officer (CMO), and Director of Quality. During this call, the facility administration confirmed that staff #1 had presented with a productive cough during the July employee health screening, and staff #1 had presented with similar symptoms for months prior to July, possibly as far back at December 2013. The administration also confirmed that staff #1 was diagnosed with contagious TB on 8/21/14, staff #1 had cared for infant patients (feeding and bathing) with present respiratory symptoms since at least July 2014, a large (yet unknown) number of infants have possibly been exposed to TB while receiving care at the facility, and the facility was working with the local health department on developing a plan to identify and notify potentially exposed patients.

The CNO said that she and the Director of Post-Partum had met with staff #1 on several occasions between 7/2/14 and 8/15/14 (last day worked), and staff #1 did not exhibit any signs of a cough during these meetings. The CNO also said that prior to 8/21/14, facility administration attributed staff #1's symptoms to allergies.

The CMO highlighted that staff #1 had been under the care of a private physician for the respiratory symptoms during the time of the employee health screening of staff #1 on 7/2/14, at which time the Occupational Health Nurse was made aware.

Based on a review of facility documents and staff interviews, it was determined that the facility failed to have a system in place to ensure that patients and visitors of the hospital are not exposed to a communicable disease.
The facility policy for annual screening of employee health failed to include important guidance for the surveillance of tuberculosis (TB). An employee demonstrated signs and symptoms of possible active TB during an annual health screening (the employee was later confirmed to have contagious TB), yet the employee was allowed to return to work. As of the exit date of the survey (9/15/14), a large (yet undetermined) number of patients and visitors had been exposed to TB by this employee, including newborn infants.


Findings were:


A report was received by the Texas Department of State Health Services (DSHS)-Health Facility Compliance unit from the DSHS Director of Infectious Disease Prevention Section, which indicated that a direct patient care employee (staff #1) working at the hospital tested positive for active TB. Staff #1 reported being symptomatic since December 2013, and Staff #1 reported coughing and hemoptysis (coughing up blood) during an annual TB screening in July 2014.

The Centers for Disease Control and Prevention (CDC), identified the following regarding TB, "The TB bacteria are put into the air when a person with TB disease of the lungs or throat coughs, sneezes, speaks, or sings. People nearby may breathe in these bacteria and become infected." The CDC also identified the following regarding TB, "Symptoms of TB disease include: ...a bad cough that lasts 3 weeks or longer...weakness or fatigue." Referenced on 9/15/2014 from the CDC .


During the onsite investigation on 9/9/14, the following information was obtained from the facility's Occupational Health Nurse, Risk Manager and staff #5 (Infection Control Personnel) during an interview on the same date, which revealed the following timeline:

- Over 10 years ago, staff #1 had both a positive TB skin test and subsequent chest x-ray, which indicated latent TB.

- Around December 2013, staff #1 had not been feeling well and was exhibiting general non-descript symptoms (including a productive cough and fatigue). During this time, and for the period following, staff #1 worked on the Post-Partum (PP) unit.

- 7/2/14, annual employee health screening by the facility's Occupational Health Nurse revealed that staff #1 had a base-line chest x-ray after a positive TB skin test, and that staff #1 presented with a productive cough and fatigue at the time of the screening. The Occupational Health Nurse was informed by staff #1 during the screening that staff #1 was being evaluated by a personal physician for the productive cough and fatigue, and no definitive diagnosis had been determined.

- 8/15/14, last day staff #1 worked at the facility...demonstrated by a document provided to the surveyor called "iSeries Timekeeper...EMPLOYEE TIME CARD". Staff # 1 continued to have respiratory symptoms and fatigue while providing direct care to newborns up to this date.

- 8/21/14, staff #1 demonstrated positive TB test results at the office of her private physician. Shortly after this, staff #1 had informed the hospital that they had active TB, and staff #1 had not returned to work, making 8/15/14 the last day worked.

- 9/4/14, by this date the hospital had begun coordinating with the local health department to develop an exposure plan. On 9/4/14, hospital administration, along with representatives from the local health department (a nurse and a physician), met with most of the current staff of the PP unit and the staff were screened for symptoms of active TB, and staff were encouraged to have a test for TB (quantiferon gold - QFG) provided by the hospital. The following documents were provided to the surveyor on 9/9/14: a roster signed by most of the PP unit staff which documented attendance of the 9/4/14 meeting; a flow-sheet which demonstrated that most of the current PP unit staff had received the QFG test, most of the results had yet to come back.


Facility policy, Annual Employee Physical Assessments (Policy #806, Original Date: 03/2007, Revised Date: 10/2010, and reviewed by the surveyor on 9/9/14), included the following regarding TB surveillance: "Sierra Providence Health Network (SPHN) requires all employees to complete an annual physical assessment by the facility's Occupational Health Nurse (OHN) to include:...4. An annual tuberculine skin test (PPD) or written documentation of a previously positive tuberculin skin test, followed up by a chest x-ray (CXR) and/or referral to the health department as appropriate."

Facility policy, Tuberculosis Exposure Plan (Policy #3, Original Date: 1/03, Review/Revised Date: 1/05; 4/07, and reviewed by the surveyor on 9/9/14), included the following regarding TB surveillance: "8 ...A. Occupational Health Department will provide employees assessments. Upon hire two step TST (tuberculin skin test) testing is conducted ...J. Personnel with a positive TST: 1. Answer the Tuberculosis risk questionnaire. 2. An x-ray is taken as a baseline reference and referred to the City County Health Department for evaluation and clearance. 3. The City County Health Department, Tuberculosis department evaluates positive findings and recommendations followed. 4. X-rays are recommended once at baseline and when clinical presentation suggests the activation of latent tuberculosis."


The facility policy, Annual Employee Physical Assessments, failed to include all of the guidance regarding TB surveillance that is found in the facility policy Tuberculosis Exposure Plan. Specifically, the policy did not include all of the guidance for employees with a positive tuberculin skin test..."X-rays are recommended once at baseline and when clinical presentation suggests the activation of latent tuberculosis."

The facility's Occupational Health Nurse had access to information which indicated that staff #1 had a baseline chest x-ray after a positive TB skin test, and staff #1 had a cough and fatigue during the annual screening, which are clinical presentations that suggest activation of latent TB. The Annual Employee Physical Assessments policy did not indicate a need for further TB evaluation, and the Occupational Health Nurse did not pursue further TB evaluation of staff #1.


A conference call was held on the afternoon of September 15th, 2014; in attendance were the Health Facility Compliance Zone 1 Manager (complaint surveyor) and Branch Manager, and the facility's Director of Infection Prevention and Occupational Health Services, Chief Nursing Officer (CNO), Chief Medical Officer (CMO), and Director of Quality. During this call, the facility administration confirmed that staff #1 had presented with a productive cough during the July employee health screening, and staff #1 had presented with similar symptoms for months prior to July, possibly as far back at December 2013.

The administration also confirmed that staff #1 was diagnosed with contagious TB on 8/21/14, staff #1 had cared for infant patients (feeding and bathing) with present respiratory symptoms since at least July 2014, a large (yet unknown) number of infants have possibly been exposed to TB while receiving care at the facility, and the facility was working with the local health department on developing a plan to identify and notify potentially exposed patients.

The CNO said that she and the Director of Post-Partum had met with staff #1 on several occasions between 7/2/14 and 8/15/14 (last day worked), and staff #1 did not exhibit any signs of a cough during these meetings. The CNO also said that prior to 8/21/14, facility administration attributed staff #1's symptoms to allergies.

The CMO highlighted that staff #1 had been under the care of a private physician for the respiratory symptoms during the time of the employee health screening of staff #1 on 7/2/14, at which time the Occupational Health Nurse was made aware.