Failure to Complete Required TB Screening for Two Residents
Penalty
Summary
The facility failed to implement proper infection control practices related to tuberculosis (TB) screening for two residents. One resident, with diagnoses including paraplegia, bipolar disorder, and chronic osteomyelitis, was admitted and had orders for a two-step TB skin test. The first step was refused by the resident, and the second step was not documented as administered. Although a TB screening tool assessment was eventually completed several months after admission, neither the first nor second step of the TB skin test was performed at the appropriate time. Interviews with the Regional Nurse Consultant (RNC) and Director of Nursing (DON) confirmed that the resident had refused all vaccines and TB skin tests, and that the TB screening tool assessment should have been completed at admission or at the time of refusal. Another resident, with diagnoses including congestive heart failure, right above-knee amputation, and kidney failure, was also admitted without documentation of either step of the two-step TB skin test. A TB screening tool assessment was completed many months after admission. The RNC and DON confirmed that this resident had not received the required TB tests upon admission, as required by facility policy. Review of the facility's TB testing policy indicated that all residents admitted from the community should have completed TB screening using the two-step method upon admission.