Failure to Implement Infection Control Precautions for Suspected TB Case
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically in the case of a resident who was admitted with multiple complex medical conditions, including cavitation pneumonia, end-stage renal disease, and diabetes mellitus. The resident had a history of hospitalizations for severe lung infections and was under suspicion for tuberculosis (TB) after a preliminary positive acid-fast bacilli (AFB) result was reported. Despite this, upon the resident's return from the hospital, the facility did not implement appropriate isolation precautions or interventions to prevent potential transmission of communicable diseases. Staff interviews and record reviews revealed that there was confusion and lack of clarity among facility staff regarding the need for isolation and the use of personal protective equipment (PPE) for the resident. The resident was allowed to participate in group activities and dine with other residents, and staff were not consistently wearing N95 masks or following airborne precautions. Multiple staff members, including nurse practitioners, licensed vocational nurses, and the DON, indicated uncertainty about the facility's protocol for handling suspected or confirmed TB cases, especially in the absence of a negative pressure room. The facility's own policies required immediate respiratory isolation and use of PPE for suspected TB cases, but these were not followed. Furthermore, after the facility received notification of a positive AFB result, no post-exposure interventions were implemented for residents or staff who may have been exposed. There was no monitoring for signs or symptoms of infection among those potentially exposed, and no chest x-rays or other assessments were conducted. Communication with the local health department confirmed that the facility was advised to use isolation and N95 masks as a precaution, but these recommendations were not fully enacted. The facility's failure to follow its own infection control policies and to implement necessary precautions placed residents and staff at risk for the development and transmission of communicable diseases.