Failure to Complete and Document TB Testing per Facility Policy
Penalty
Summary
The facility failed to ensure tuberculosis (TB) testing was completed according to its own policy and procedure for two of three residents reviewed. Interviews with multiple licensed vocational nurses (LVNs) revealed that TB tests were required to be completed within 24 hours of admission and documented in the electronic Medication Administration Record (eMAR). However, record reviews showed that for one resident, there was no documentation that a TB test was completed within 24 hours of admission, and for another resident, there was no documentation that the first step of the TB test was conducted. Additionally, for the second resident, although the first step TB test was administered, there was no documentation that the test was read within the required 72-hour window, nor was there documentation that the second step TB test was completed. The Infection Preventionist confirmed that newly admitted residents should receive TB testing within 24 hours, with results read within 72 hours, and that documentation should be consistent across the immunization record and eMAR. Review of the facility's policy indicated that a two-step Mantoux Tuberculin Skin Test (TST) should be performed and documented for residents not previously admitted. The lack of documentation and failure to follow the established TB testing protocol for these residents constituted a deficiency in the facility's infection prevention and control program.