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Based on observation, interview and record review it was determined the facility failed to monitor compliance with their policies regarding infection control 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 in the Dialysis Unit.

The findings include:

Review of the hospital policy relating to the Screening Program on 10/20/10 revealed "The tuberculin skin test is the method of choice for TB screening.....A two step procedure is used to minimize the likelihood of misinterpreting a boosted reaction as a true conversion due to recent infection" After the initial TB screening test, policies for repeat are based upon the CDC facility assessments, which are done annually. Review of the policy failed to address the staff requirement to provide documentation for any previous TST testing.

Interview with the Department Service 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 9/21/10; 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 Infection Control Director on 10/20/10 at 1:00 PM revealed there were six (6) patients who received exposure to the Contract Dialysis Nurse, however one of patients had expired.

Interview with the Chief Nursing Officer at St Mary's and Elizabeth Hospital on 10/21/10 at 7:55am revealed she keeps a separate file for the local Dialysis Service contracts and stated there was a sign-off sheet that is kept in each contract employee's file, which tells if there had been previous exposure; however, since the contract dialysis nurse had a negative chest Xray on hire, they thought this was sufficient. The Nursing officer stated they make sure chest x-rays are to be completed annually, or if there have been exposure.

Review of the Morbidity and Mortality Weekly Report (MMWR recommendations and reports 12/30/2005) regarding indications for two-step tuberculin skin test (TST's) revealed previous undocumented positive TST results 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), documented, administer two-step TST's or offer BAMT (Blood Assay for Mycobacterium Tuberculosis).