Failure to Document Training and Proper Administration of TB Skin Tests
Penalty
Summary
The facility failed to ensure that staff administering and reading Mantoux skin tests for tuberculosis (TB) had documented training, and did not consistently document all required elements of the TB testing procedure. Specifically, there was no documentation of the time the second step Mantoux test was administered or read for one employee, making it impossible to confirm the required 48-hour interval before reading the test. Additionally, for three residents, clinical records showed that TB skin tests were administered and read by nurses without documentation of required training, and in some cases, the tests were read before the 48-hour minimum had elapsed. The facility's own policies required that Mantoux tests be administered and read by staff with documented training and that the date and time of administration and reading be recorded. Residents involved had complex medical histories, including conditions such as spina bifida with hydrocephalus, type 2 diabetes mellitus, paraplegia, cerebral palsy, chronic respiratory failure, dementia, and other significant diagnoses. The records for these residents showed missing documentation of the time of TB test administration and reading, and in some cases, the tests were read too early. Interviews with the Infection Prevention Nurse and the Director of Nursing confirmed that the required training documentation was missing for several nurses, and that the facility could not verify training for some staff members.