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Based on interview and document review, in one (1) of eight (8) incidents reviewed, it was determined the facility failed to conduct a complete investigation in a timely manner of a complaint related to a patient discharged from the facility who had Tuberculosis.

Findings include:

The document titled "Performance Improvement/Patient Safety Plan, 2023-2024" states, "In order to identify the factors that underlie or contribute to the undesirable variation in performance, the organization shall conduct a Root Cause Analysis (RCA). The multi-disciplinary RCA team is charged with analysis of the single event, identification of contributing factors, and the development of a root cause statement that when reliably corrected, will decrease the likelihood of a similar event. Additionally, cultural components, environmental and cognitive factors impacting the event shall be incorporated into the analysis."

Review of the incident log for 2023 revealed there was no data related to a complaint of patient discharged from the facility who had Tuberculosis.

During an interview conducted on 11/30/23 at 9:55 AM with Staff A, Program Director Infection Prevention Committee, Staff A stated that a nurse from the County Department of Health (DOH) alleged during a phone call on 10/27/23, that a patient (MR #1) was treated and released from Northern Westchester Hospital with a communicable reportable disease (Tuberculosis) without the facility notifying the County Department of Health as required by New York State Public Health law. Staff A stated she sent an email that day (10/27/23) to the Director, Chief Medical Officer, the Infectious Disease Medical Doctor, Director of the Emergency Department, and the Director of Nursing in the Emergency Department.
Staff A acknowledged that she had not taken any further action and that a root cause analysis would be done on 12/6/23.

There was no evidence that the facility completed a root cause analysis to identify the issues and implement corrective actions to prevent recurrence.

These findings were shared with Staff C, Director of Regulatory Affairs on 12/4/23 at approximately 3:15 PM.

Based on medical record review, document review and interview, in one (1) of 20 medical records reviewed, it was determined the facility failed to (a) implement methods to prevent and control the transmission of infections within the hospital and between the hospital and other settings and (b) collaborate with the quality assessment performance improvement program on infection prevention and control issues. This was evident for MR #1.

This failure placed patients, visitors, and staff at the hospital and members of the community at risk for contracting a reportable airborne communicable disease.


Findings include:

The facility failed to identify and appropriately screen a patient who had symptoms of a Tuberculosis infection when the patient was in the emergency department on 2/26/23 and 10/21/23 and (b) screen in a timely manner, patient(s), staff, and visitors who were exposed to a patient who had symptoms of a Tuberculosis infection.

See findings at A 0749.


The facility failed to ensure that the infection control program collaborated with the quality assessment performance improvement program to control the exposure and spread of the infection in the hospital and the community.

See findings at A 0774.

Based on medical record review, document review and interview, in one (1) of 20 medical records reviewed, it was determined the facility failed to identify and screen staff, patients and visitors who were potentially exposed to an airborne reportable communicable disease. This was evident in MR #1.

Findings include:

The policy titled "Tuberculosis Screening, Repeat Testing, and Management of Occupational Exposures," approved 6/2/22, states "When an individual meets the high or moderate risk category, they need post-exposure TB screening when not wearing an N95 respirator. High risk Health Care Personnel (HCP) individuals with the highest risk of transmission of M. tuberculosis perform the following activities for any duration of time such as: (4) induce sputum or other cough-generating procedures, and for moderate risk HCP: HCP who are directly involved in patient care or close patient contact. When an individual meets the moderate risk category, they need post-exposure Tuberculosis screening. This category includes HCP who are not performing aerosolizing procedures, but are assigned to the patient's care area, (i.e., room or designated location when it is an open ward) and have close, direct patient contact for greater than: at least one (1) hour of cumulative exposure when the patient is smear positive for M. tuberculosis."

Review of MR #1 revealed this 73 year-old patient presented to the Emergency Department (ED) on 2/26/23 at 2:13 PM with complaints of cough x 2 months, not eating and weight loss. A significant finding was the chest x-ray read at 3:39 PM showed there was "mild to moderate perihilar infiltrates and patchy consolidation/atelectasis/effusion at the right base evident. Impression: mild to moderate perihilar interstitial infiltrates bilaterally. Patchy consolidation/atelectasis/effusion at the right base." The patient was diagnosed with Pneumonia and discharged from the Emergency Department at 5:48 PM, more than three (3) hours after he arrived in the Emergency Department.

The patient returned to the Emergency Department on 10/21/23 at 3:47 PM with hemoptysis x 2 days. The significant finding was a CT-Scan of the chest was performed and the radiologist noted at 8:03 PM "diffuse bronchiectasis. Extensive consolidative changes in the right lower lobe with multifocal areas of cavitating nodularity some of which communicates with the adjacent bronchus as well as innumerable nodular densities throughout the lung fields, right lung greater than the left, may represent extensive infectious or inflammatory etiology however neoplastic etiology cannot be ruled out."

The Emergency Department doctor documented at 8:15 PM that a CT-Scan of the chest showed "the patient has extensive consolidative changes and numerous cavitating nodules some of which communicate with the adjacent bronchus which likely explains hemoptysis." The doctor also documented a message was sent to the radiologist to ask if the imaging is consistent with Pulmonary Tuberculosis. The radiologist documented an addendum note at 8:20 PM which indicated "Differential diagnosis includes fungal infection and Tuberculosis cannot be excluded."

The Emergency Department doctor documented "Sputum tests to include culture, fungal infection and AFB (acid fast bacilli for Tuberculosis detection) culture were ordered; however, patient is having difficulty producing sputum for the test. Will allow an additional 20 minutes or so for patient to attempt to produce some sputum, otherwise these tests will need to be performed in the outpatient setting." The patient was discharged from the Emergency Department at 9:27 PM, almost six (6) hours after arrival to the facility.

There was no evidence that airborne, or isolation precautions were implemented throughout either of the patient's Emergency Department visits.

The survey team arrived at the facility on 11/29/23 and notified the facility that the team would be conducting a survey for the Condition of Participation for Infection Prevention and Control and Antibiotic Stewardship Program.
The following day, 11/30/23 at 10:11 AM, the Chief Medical Officer confirmed the facility's failure to identify and report to the Department of Health MR #1's Tuberculosis diagnosis.

During an interview conducted on 11/30/23 at 11:50 AM with Staff D, Section Chief Pulmonary Program Director, confirmed the likelihood that the patient had Tuberculosis on the 2/26/23 and based on the findings on the x-ray should have been admitted and treated until three (3) negative sputum samples were obtained for Acid Fast Bacilli.

On 11/30/23, the facility began to trace and screen staff that were exposed to the infectious patient; on 12/4/23 identified and screened a roommate and the roommate's mother that were exposed to the patient.

The facility failed to follow its policy and implement measures to minimize the risk of transmission of a communicable airborne disease and implement post exposure screening of staff, visitors, and other patients for a reportable communicable disease in a timely manner.

These findings were shared with Staff C, Director of Regulatory Affairs on 12/4/23 at approximately 3:15 PM.

Based on document review and interview, it was determined the facility failed to ensure that the infection control program collaborated with the quality assessment improvement program to control the exposure and spread of an infection.

Findings include:

The document titled "Performance Improvement/Patient Safety Plan 2023-2024" states, "To achieve its goals, Northwell Health shall review and outline infection prevention activities and epidemiology methodologies that reduce the risk of acquisition and transmission of hospital acquired infections. Data concerning infections shall be systematically collected, analyzed, and regularly reviewed by organizational and hospital leadership. The reduction of hospital acquired infections shall be integrated into the Strategic Plan for Clinical Excellence and Quality/Patient Safety and shall provide a framework for reducing the risks of infection."

During an interview conducted on 11/30/23 at 9:55 AM with Staff A, Program Director Infection Prevention Committee, Staff A stated that a nurse from the County Department of Health (DOH) alleged during a phone call on 10/27/23 that a patient (MR #1) was treated and released from Northern Westchester Hospital with a communicable reportable disease (Tuberculosis) without the facility notifying the County Department of Health as required by New York State Public Health law. Staff A stated she sent an email that day (10/27/23) to the Director of the Chief Medical Officer, the Infectious Disease Medical Doctor, Director of the Emergency Department, and the Director of Nursing in the Emergency Department.

Staff A confirmed the patient was in the Emergency Department on 2/26/23 and 10/21/23 with symptoms of a Tuberculosis infection. Staff A acknowledged that she had not taken any further action and that a root cause analysis would be done on 12/6/23, more than nine (9) months after the first potential exposure on 2/26/23 and more than six (6) weeks after the last exposure on 10/21/23.

Review of the infection control minutes for 2023 revealed there was no documentation of patient MR #1 communicable disease incident. The staff, patient, visitors, and community exposure to MR # 1 Tuberculosis infection was not documented as being addressed at these meetings.

Review of the quality assessment performance minutes for 2023 revealed there was no documentation that this incident was analyzed, or any corrective measures were discussed and implemented for the exposures.

These findings were shared with Staff C, Director of Regulatory Affairs on 12/4/23 at approximately 3:30 PM.