Failure to Provide Timely Two-Step TB Skin Test on Admission
Penalty
Summary
The facility failed to ensure that a resident was provided a two-step tuberculin skin test (TST) upon admission, as required by facility policy. The resident, who had diagnoses including chronic respiratory failure, chronic pulmonary edema, and type 2 diabetes mellitus, was admitted on 3/29/25. The clinical record showed that the resident received a first step TB skin test on 3/29/25 and another first step TB skin test on 4/30/25, with both tests read as negative. However, the two tests were administered 32 days apart, and both were labeled as first step TB skin tests, with no timely second step documented. Facility policy required that if the first TST is negative, a follow-up TST should be administered 1 to 3 weeks after the initial test is read, which was not followed in this case.