Failure to Implement Proper Infection Control for Suspected Tuberculosis Case
Penalty
Summary
The facility failed to follow infection control standards in the management of a resident suspected of having tuberculosis (TB). According to the facility's own policy, residents with suspected or confirmed TB should be immediately placed on droplet precautions pending transfer, and only admitted if the facility is equipped with a private airborne infection isolation room. The resident in question had a positive PPD test and subsequent positive QuantiFERON gold test, with chest x-rays that could not rule out TB. Despite these findings, the care plan was not updated to reflect the suspicion of TB, the initiation of droplet precautions, or the treatment for pneumonia. The facility did not notify the local health jurisdiction (LHJ) promptly after the positive PPD test, waiting six days before making contact. Staff interviews revealed uncertainty about the correct type of precautions for TB, with the Director of Nursing Services (DNS) acknowledging that airborne precautions are typically required for TB, not droplet precautions as stated in the facility's policy. There was also a lack of documentation and timely communication with the LHJ regarding the resident's status and the facility's actions. Additionally, the facility did not implement interventions for possible TB exposure among staff or other residents, relying instead on verbal communication for monitoring signs and symptoms. The care plan was not reviewed or updated at key points when new information about the resident's condition became available. These lapses in infection control practices and communication placed residents, staff, and visitors at risk for contracting and spreading infections.