Failure to Report Tuberculosis Case to State Health Department
Penalty
Summary
The facility failed to report a case of tuberculosis (TB) to the Pennsylvania Department of Health (DOH) through the state Event Reporting System, as required by regulation. This deficiency was identified during a review of clinical files, facility documentation, and staff interviews. The Director of Nursing confirmed that a resident had tested positive for TB, and while the facility collaborated with the local county to report the case and implement recommended measures, they did not notify the DOH state survey agency. The Nursing Home Administrator also confirmed this failure to report the TB infection as required by the regulation.
Plan Of Correction
1. Employee E2 submitted reportable to Department of Health. 2. Facility will review incident reports and any new infection diagnosis for past 30 days to identify any missed reportable. 3. Director of Nursing will be re-educated on event reporting requirements. 4. The DON/designee will complete random audit to ensure all reportable events have been submitted to DOH reportable system weekly for four weeks and monthly for three months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations.