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BAPTIST MEMORIAL REHABILITATION HOSPITAL
INFECTION CONTROL PROFESSIONAL
Tag No.: A0748
Based on policy review, record review and interview, the facility failed to conduct surveillance on a hospital wide basis in order to identify infectious risk or communicable disease.
The findings included:
Review of the facility's "Hospital Wide Infection Prevention Plan" policy revealed, " ...The Infection Control Plan defines the structure and activities for surveillance, prevention, and control of infections among patients, employees ...Goals and objectives: C. Employ hospital wide surveillance, collect analyze and trend data ..."
Review of the facility's "TB Risk Assessment 2017" revealed, " ...Healthcare Worker (HCW)... Employee Health Services (EHS) TEST EMPLOYEES UPON HIRE, ANNUALLY AND POST-EXPOSURE ...Recommendations ...Schedule annual...PPD [Purified Protein Derivative] skin testing or screening to correspond with time of performance evaluations ...Monthly reminders email sent to managers for staff due that month-reminder sent on first day of month and again mid-month ..."
Review of the facility's staffing list provided by the Infection Control Nurse revealed 31 of 190 staff are currently past due for TB skin test.
In an interview on 5/22/18 at 2:25 PM, the Director of Quality Management (DQM) stated she had received a telephone call from (named health care facility) stating that one of the hospital employees was undergoing treatment for Tuberculosis and had been placed on home isolation by (named health care facility). The (named health care facility) informed me that the employee had returned to work 3 days before isolation was to end. At that time we immediately took (named employee) off the schedule.
In an interview on 5/22/18 at 3:11 PM, the Infection Control Nurse (ICN) stated she had been in the position for 2 weeks. The ICN stated she had identified several employees had past due TB [PPNskin test when updating employee health records. The ICN stated she had informed the department managers of the employees who were past due. The ICN stated the employee should be tested up on hire, before providing care, employees should have 2 negative TB skin test then annually screened.