CMS report: TB-infected Providence Memorial worker showed symptoms, coughed up blood in July health screening

A Center of Medicare and Medicaid Services investigation into the tuberculosis exposure at Providence Memorial Hospital, is summarized in a 30-page document.

Based on reviewing facility documents and staff interviews, CMS found the infected healthcare worker showed signs and symptoms of active TB during an annual health screening, including coughing up blood, in July.

Yet, the worker was allowed to return to work in the nursery with newborn babies until Aug. 15.

CMS is blaming the hospital’s governing board for failing to ensure the safety of its patients.

Here’s the report’s timeline:

December 2013- A patient care tech, CMS calls Staff #1, reported that the symptoms started.
July 2014- Staff #1 showed symptoms during an annual TB screen. Up until this point, Staff #1 had been working in the Post-Partum unit.
Between July and August the report said administrators met with Staff #1. They attributed the worker’s symptoms to allergies.
August 15th was Staff #1’s last day of work. This worker went to a private physician after the 15th, and was told tests for active TB were positive. Staff #1 told Providence, and never came back to work.
September 4th- Providence began coordinating with the local health department.

The question on everyone’s mind is how did this happen?

It appears CMS wants to know the same thing.

The report states “The facility policy for annual screening of employee health failed to include important guidance for the surveillance and control of TB. An employee demonstrated signs and symptoms of possible and active TB during an annual health screening, yet the employee was allowed to return to work.”

CMS found the Annual Employee Physical Assessment failed to include all necessary guidance, specifically not ensuring positive skin tests are supported by X-Rays as well.

Providence agrees their policies are lacking. The report says Governing Board takes full responsibility. It began implementing a plan of correction August 22nd:

The New Employees and Annual Assessment Policy and Procedure mandates that if skin test is positive or questionnaire indicates symptoms of active TB disease, the worker will not be able to return to work until additional follow-up testing has been received.
New hires with history of positive skin test will provide documentation and have chest X-rays.
If the worker is converting from a negative skin test, he or she will have chest X-rays and be referred to the city/county clinic for follow up and treatment.
TB symptoms are clarified. They include coughing up blood, pain in chest, chills, fever, etc.
The occupational health nurse will be re-trained and re-tested in these new policies annually.
Providence will audit itself, combing through 30 healthcare worker files per month for six months to ensure 100-percent compliance with the new policies. If they’re not 100-percent compliant, the audit will continue until they are.
Providence hired consulting firm Enviro Team North America to investigate the mechanical equipment, air exchange, indoor air quality and pressure conditions,. The results will be completed on Thursday. From there, Providence will implement the necessary corrective actions.

The report also lists those responsible: the hospital CEO, the chief Nursing Officer, the Human Resources Director, the Chair of Infection Control Committee, and the Chief Medical Officer of the Sierra Providence Health Network.