Robson Reserve at Pebblecreek

Based on documentation review, record review, and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for four of nine caregivers sampled. The deficient practice posed a TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E5's personnel record revealed documentation that showed E5's second TB skin test was read 10 days after hire. 4. A review of E7's personnel record revealed documentation that showed E7's second TB skin test was read 14 days after hire. 5. A review of E8's personnel record revealed documentation that showed E8's second TB skin test was read 17 days after hire. 6. A review of E9's personnel record revealed documentation that showed E9's second TB skin test was read 22 days after hire. 7. In an interview, E1 acknowledged E5, E7, E8, and E9 were providing services at the facility and the personnel records did not contain evidence of freedom from infectious tuberculosis(TB) as specified in R9-10-113.