The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

KING'S DAUGHTERS' MEDICAL CENTER 2201 LEXINGTON AVENUE ASHLAND, KY 41101 Sept. 28, 2012
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and review of the facility's policy, it was determined the facility failed to develop and maintain a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. Furthermore, it was determined the facility failed to report to the health department suspected or probable tuberculosis diagnoses for two (2) patients (Patients #2 and #4) in the selected sample of ten (10) patients. The facility failed to contact the health department in accordance with the facility's policy and state law.

The findings include:

Review of the facility's policy titled, "Infection Control", dated 03/12, under Section 1 (E), Subject: Reporting Diseases to the State Health Department, revealed the facility should report immediately by phone to the local health department or the KY Department for public health all unexpected patterns of cases, suspected cases or deaths which may indicate a newly recognized infectious agent, outbreaks, epidemic related public health hazard or act of bioterrorism. Furthermore, Kentucky Disease Surveillance requires priority notification to the local or state health department within one (1) business day upon recognition of a case or suspected case of Tuberculosis.

1. Record review revealed the facility admitted Patient #2 on 09/19/12 at 6:06 PM through the emergency department with diagnoses which included Cavitary Lesion of Lung, Shortness of Breath, Cardio-Pulmonary Disease Exacerbation, Acute Respiratory Distress and Pneumonia.

Review of Patient #2's record revealed a chest X-ray was obtained on 09/19/12 at 6:43 PM, with an impression of cavitary lesion in the right lung apex with a differential diagnosis which include Tuberculosis (TB). A chest Computerized Tomography Angiogram, with and without Contrast, was completed on 09/20/12 with findings that could be sequela due to TB versus chronic infected bullous/fungal infection versus malignancy. Further record review revealed a sputum report obtained on 09/21/12 at 2:29 PM which was positive for many Acid Fast Bacilli. Additionally, a progress note electronically signed by the Physician on 09/21/12 stated "Treatment for presumed TB initiated; maintain isolation; health department alerted; ID and Pulmonary following". However, there was no documented evidence Patient #2's case was reported to the local health department until 09/25/12.

Interview, on 09/28/12 at 2:45 PM, with the Infection Control Coordinator revealed her normal process was to report suspected cases of Tuberculosis to the health department immediately. Interview further revealed that had Patient #2's laboratory report on 09/21/12 with results as "many acid fast bacilli" been reported to her, she would have reported it to the health department. The interview further revealed that she expects to be notified and should have been notified of these and all suspected or potential cases of Tuberculosis.

Interview on 09/28/12 at 4:00 PM, with the Director of Accreditation, Regulatory Affairs, Patient Safety and Infection Control revealed that all confirmed cases of Tuberculosis should be reported within one (1) business day to the health department. Additionally, it was the facility's process to call the health department with suspected cases.

2. Record review revealed Patient #4 received a chest X-ray in this facility while a patient in the Emergency Department on 04/08/12.

Record review revealed, Patient #4 had previously been a patient in the Emergency Department on 04/08/12 at 1:44 AM with a chief complaint of stab wound to the shoulder. A chest X-ray was ordered on [DATE] at 2:19 AM and on 04/08/12 at 3:08 AM, a preliminary report was faxed to the Emergency Department with the impression of Bilateral upper lung apical densities may be acute or chronic. Infectious, inflammatory or granulomatous disease including Tuberculosis should be considered. Patient #4 signed himself out of the facility on 04/08/12 at 3:32 AM. Patient #4 re-entered the facility as a Directed Admit on 09/20/12 from a local correctional institution with a diagnosis of Active TB.

Review of Patient #4's History and Physical, dated 09/20/12, revealed the patient was told in 04/12 that his chest X-ray showed possible TB and that "the patient chose not to pursue treatment". Record review revealed no documented evidence Patient #4's Emergency Department visit with the chest X-ray of potential Tuberculosis was reported to the local health department.

Interview, on 09/28/12 at 2:45 PM, with the Infection Control Coordinator revealed her normal process was to report suspected cases of Tuberculosis to the health department immediately. Interview further revealed that had Patient #4's chest X-ray of 04/08/12 been reported to her, she would have reported it to the health department. The interview further revealed that she expects to be notified and should have been notified of these and all suspected or potential cases of Tuberculosis.

Interview, on 09/28/12 at 4:00 PM, with the Director of Accreditation, Regulatory Affairs, Patient Safety and Infection Control revealed that all confirmed cases of Tuberculosis should be reported within one (1) business day to the health department. Additionally, it was the facility's process to call the health department with suspected cases.

3. Review of the facility's policy titled, "Infection Control", dated 03/12, under Section 3 (K) C, revealed all units and/or departments that had staff that may have to enter an airborne isolation room, must keep an adequate supply of each size of the N-95 respirator for their staff. Further review of the policy under Care and Storage, revealed N-95 respirators shall be readily available in areas where they are used, on the isolation containers and the storage area for that department. Continued review revealed, under Attachment D and Attachment E, the negative pressure patient room must be checked by Plant Operations to ensure negative air pressure before a patient may be admitted for the purpose of airborne isolation precautions.

Observation, on 09/27/12 at 11:15 AM, revealed Room 3B140, a negative pressure isolation room with a door module for isolation supplies, to have only one (1) size N-95 (respiratory isolation mask) available for use. Further observation revealed Room 3C158, a negative pressure isolation room with a door module for isolation supplies to have only one (1) size N-95 mask available for use.

Review of the facility's Negative Pressure Log, revealed no documented evidence of Room 3B140 (Patient #2) or 3C158 (Patient #4) having the facility required Negative Pressure Test performed by the Plant Operations designated personnel prior to the patient being placed into the airborne isolation.

Interview, on 09/28/12 at 2:45 PM, with the Infection Control Coordinator revealed when airborne precautions were place, there should be both sizes of the N-95 respiratory isolation masks available for use to have a proper fit. Furthermore, Plant Operations should have conducted the negative pressure test on the isolation rooms prior to the patients being placed into the rooms per the facility's policy.

Interview, on 09/28/12 at 4:00 PM, with the Director of Accreditation, Regulatory Affairs, Patient Safety and Infection Control revealed that when a patient was in respiratory isolation there should be both sizes of the N-95 respiratory isolation masks available at the door for the staff to select the size that they have been fit tested for optimal use. Interview further revealed that the Plant Operations Department did not test the isolation rooms for negative pressure prior to the patients being placed into the room, per the facility's policy.