Failure to Complete and Document Required TB Screening and Annual Examinations for Staff
Penalty
Summary
The facility failed to ensure that staff completed required annual and upon-hire Tuberculin (TB) skin tests, maintained TB skin test results on file, and completed annual physical examinations for four out of seven employees reviewed. Specifically, one nurse did not have annual TB skin tests for two consecutive years, another nurse had no documented TB test result, a treatment nurse had neither a TB skin test nor result on file, and an occupational therapist lacked documentation of abuse training since hire. Additionally, there were missing background checks, annual skills competencies, and abuse training for some staff members. These findings were identified during interviews and concurrent record reviews with the Director of Staff Development (DSD) and the Director of Nursing (DON), who both acknowledged the requirements for annual TB testing and competencies. The DSD was uncertain about the required retention period for employee documents and confirmed that the facility's policy mandates TB screening for all new hires before duty assignment and annually thereafter. Record reviews confirmed the absence of required TB skin tests and other documentation in several employee files. The DON stated that annual TB testing and competencies are necessary to prevent staff from forgetting essential care skills. The facility's policy and procedures also require screening for latent TB infection and active TB prior to employment and annually, but these were not consistently followed for the staff reviewed.