Incomplete Documentation of TB Screening for DON
Summary
The facility failed to provide documented evidence of the results of the Director of Nursing Services' (DNS) annual tuberculosis (TB) infection screening on the required examination form. During a review of the DNS's personnel record, it was found that the most recent annual TB exam did not indicate whether the result was positive or negative for TB. This omission was confirmed during an interview and record review with Human Resources, who acknowledged that the TB exam documentation for the DNS was incomplete and lacked the necessary result information.
Plan Of Correction
DNS's personnel record was reviewed by DNS, Clinical Care Manager, Medical Director, and Administrator on 6/5/2025. The document was corrected and updated to reflect a negative TB result on 6/7/2025. The facility's Clinical Care Manager, DNS, Medical Director, and Administrator are responsible for the correction. Results of TB screening, examinations, and completion of forms will be conducted by the Clinical Care Manager. The Facility QA Manager will perform quarterly audits of initial health exams and annual exams to monitor for ongoing compliance. The DNS personnel file was corrected on 6/7/2025. Further issues regarding Employee Health Exams and/or Health Records will be brought to the QA/QAPI Committee for review at least quarterly, or with more frequency if an issue is identified. The Clinical Care Manager, DSD, DNS, Medical Director, and Administrator shall be responsible to monitor for ongoing compliance.
Penalty
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