Failure to Follow TB Testing and Documentation Protocols
Penalty
Summary
The facility failed to follow appropriate tuberculosis (TB) testing and documentation protocols for three residents, as required by professional standards and the facility's own policies. For one resident, the electronic Medication Administration Record (eMAR) entry for the administration of the Purified Protein Derivative (PPD) solution was left unsigned and blank, with no documentation in the progress notes to indicate whether the PPD was administered. The Director of Nursing (DON) confirmed that it was expected for eMAR entries to be signed and not left blank, and the facility's policy required TB screening for all residents, though it did not address documentation specifics. Another resident received two PPD administrations on consecutive days due to a lack of communication and incomplete documentation. The admitting nurse failed to document the initial administration, leading the Assistant DON to instruct another nurse to administer the PPD again the following day. This resulted in a duplicate administration, which was only discovered after the resident's representative notified the facility. The involved staff confirmed the sequence of events and acknowledged the error. For a third resident, the records showed that the first step of the two-step PPD test was administered, but there was no documented evidence that the result was read or that it was negative before proceeding to the second step. Additionally, the documentation for the reading of the second step was unclear, with a code used that did not have a corresponding explanation in the facility's chart codes. Interviews with nursing staff revealed uncertainty about the correct procedures when a resident is hospitalized during the testing period, and the DON acknowledged the required protocol for reading and documenting PPD results.