Failure to Implement Airborne Precautions for TB Evaluation
Penalty
Summary
The facility failed to implement airborne precautions for a resident who was being evaluated for tuberculosis (TB). The resident was admitted with a history of cerebral infarction and, following a physician's order, received a TB test and subsequently had a chest x-ray ordered to rule out TB. An order for airborne precautions, including the use of N95 masks and keeping the resident's room door closed, was issued. However, the resident continued to participate in physical therapy and group sessions in communal areas without wearing a mask, and staff did not consistently use personal protective equipment (PPE) when entering the resident's room. The airborne precaution sign on the resident's door was handwritten and did not provide full instructions, and the door to the shared room was often left open with other residents present. Multiple staff members, including CNAs and LPNs, reported entering the resident's room and assisting the resident without PPE, and were unaware of any specialized infection control practices required. The resident confirmed that staff did not consistently wear PPE and that they were not instructed to wear PPE or sanitize hands when outside the room or during therapy. The Director of Nursing Services acknowledged that the airborne precautions were not fully implemented as required, and that staff were expected to follow these precautions until the chest x-ray results were received.