Failure to Administer Second TB Test per Protocol for New Employee
Penalty
Summary
The facility failed to ensure that a housekeeping aide received appropriate tuberculosis (TB) testing in accordance with state and federal guidelines. Upon hire, the employee completed a baseline TB symptom screen and received both the first and second tuberculin skin tests (TST) on the same day, with both tests read two days later and found to be negative. However, both the Minnesota Department of Health and CDC guidelines require that if the first TST is negative, the second TST should be administered 1 to 3 weeks after the first, not on the same day. Documentation in the employee's health file indicated that the tests were not spaced appropriately, and there was no evidence that a second TST was completed at the correct interval. Interviews with the housekeeping aide revealed she was not informed that a second TST was required, and the Assistant Director of Nursing (ADON) acknowledged that the TB screening form was filled out incorrectly and that the second TST was not properly documented or administered according to policy. The facility's policy required all employees to be screened and tested for active TB prior to employment, but this process was not followed for the housekeeping aide, resulting in a failure to comply with TB control regulations.