VI AT GRAYHAWK, A VI AND PLAZA COMPANIES COMMUNITY

Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for four of five personnel sampled. The deficient practice posed a potential illness 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 E1's personnel record revealed a hire date of August 2023. E1's personnel record included a negative TST within 12 months prior to hire, an assessment of risks of prior exposure to infectious TB, and a determination of signs or symptoms of TB. However, no second TST was available for review. 4. A review of E2's personnel record revealed a hire date of January 2024. E2's personnel record included a negative TST within 12 months prior to E2's hire date. However, no second TST, assessment of risks of prior exposure to infectious TB, or determination of signs or symptoms of TB was available for review. 5. A review of E3's personnel record revealed a hire date of May 2022. E3's personnel record included a negative TST within 12 months prior to hire, an assessment of risks of prior exposure to infectious TB, and a determination of signs or symptoms of TB. However, no second TST was available for review. 6. A review of E4's personnel record revealed a hire date of August 2022. E4's personnel record included a negative TST within 12 months prior to E4's hire date. However, no second TST, assessment of risks of prior exposure to infectious TB, or determination of signs or symptoms of TB was available for review. 7. In an interview, E1 and E6 acknowledged E1, E2, E3, and E4 did not provide evidence of freedom from infectious TB as specified in R9-10-113.

Based on record review and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for four of five residents sampled. The deficient practice posed a potential illness 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 R2's, R3's, R4's, and R5's medical record revealed documentation of R2's, R3's, R4's, and R5's freedom from infectious tuberculosis. However, assessment of risks of prior exposure to infectious TB or determination of signs or symptoms of TB was not available for review. 3. In an interview, E1 and E6 acknowledged R2's, R3's, R4's, and R5's medical record did not contain documentation of the resident's freedom from infectious tuberculosis as specified in R9-10-113.