OSHA Inspection: SUMMERLIN HOSPITAL MEDICAL CENTER

Issued

2014-04-09 00:00:00

Abate by

2014-05-12 00:00:00

Penalty

Initial $6300.00 · Current $0.00 Reduced

General-duty citation text

Nevada Revised Statute 618.375(1): Duties of employers. Every employer shall fur
nish employment and a place of employment which are free from recognized hazards
that are causing or are likely to cause death or serious physical harm to his o
r her employees: 1)Prior to this inspection, Summerlin Hospital Medical Center's
most recent Tuberculosis (TB) Risk Assessment did not include statistical data
related to a 2013 significant workplace exposure to Mycobacterium tuberculosis.
At least two patients with unrecognized tuberculosis (TB) disease were admitted
into the hospital and cared for by staff, exposing employees to Mycobacterium tu
berculosis and subsequently causing 20 employees to
contract tuberculosis and exhibit either active or latent forms of the infection
. A TB Risk Assessment that included this data is necessary so the quality of th
e hospital's TB infection control can be properly evaluated, and needed improvem
ents in infection control measures can be identified. 2)Since the recent workpla
ce exposure to Mycobacterium tuberculosis, Summerlin Hospital Medical Center has
not followed its own TB Exposure Control Plan that states a "Risk Evaluation" w
ill be conducted in the event of an exposure. Prior to this inspection, Summerli
n Hospital Medical Center did not conduct a Tuberculosis (TB) Risk Assessment th
at included statistical data related to a 2013 significant workplace exposure to
Mycobacterium tuberculosis. A feasible and accepted abatement method for reduci
ng these hazards is to follow Summerlin Hospital Medical Center's TB Exposure Co
ntrol Plan which requires a Risk Assessment to be conducted in the event of an e
xposure. The Assessment should include data regarding the specific exposure. Fur
thermore, conducting TB Risk Assessments on
an ongoing basis would reduce this hazard, as recommended by the Center for Dise
ase Control and Prevention (CDC) in the 2005 "Guidelines for the Transmission of
Mycobacterium tuberculosis in Health Care Facilities." The Assessment should be
completed following the requirements of the TB Risk Assessment section. Referen
ces: 1) Nevada Administrative Code 441A.200: Infectious Diseases. List of adopte
d recommendations, guidelines and publications; review of revision or amendment
of adopted recommendation, guideline or publication: The following recommendatio
ns, guidelines and publications are adopted by reference: (h) The recommendation
s of the Centers for Disease Control and Prevention for preventing the transmiss
ion of tuberculosis in facilities providing health care set forth in "Guidelines
for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Se
ttings,
2005," Morbidity and Mortality Weekly Report[54(RR17):1-141, December 30, 2005].
2) "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in
Health Care Facilities," 2005. Centers for Disease Control and Prevention (CDC)
, MMWR December 30, 2005/Vol. 54/No. RR-17. TB Risk Assessment for Settings in W
hich Patients with Suspected or Confirmed TB Disease Are Expected To Be Encounte
red The initial and ongoing risk assessment for these settings should consist of
the following steps: 1. Review the community profile of TB disease in collabora
tion with the state or local health department. 2. Consult the local or state TB
control program to obtain epidemiologic surveillance data necessary to conduct
a TB risk assessment for the health-care
setting. 3. Review the number of patients with suspected or confirmed TB disease
who have been encountered in the setting during at least the previous 5 years.
4. Determine if persons with unrecognized TB disease have been admitted to or we
re encountered in the setting during the previous 5 years. 5. Determine which HC
Ws need to be included in a TB screening program and the frequency of screening
(based on risk classification) (Appendix C). 6. Ensure the prompt recognition an
d evaluation of suspected episodes of health- care-associated transmission of M.
tuberculosis. 7. Identify areas in the setting with an increased risk for healt
h-care-associated transmission of M. tuberculosis, and target them for improved
TB infection controls. 8. Assess the number of AII rooms (Formerly called negati
ve pressure isolation
room, an AII room is a single-occupancy patient-care room used to isolate person
s with suspected or confirmed infectious TB disease) needed for the setting. The
risk classification for the setting should help to make this determination, dep
ending on the number of TB patients examined. At least one AII room is needed fo
r settings in which TB patients stay while they are being treated, and additiona
l AII rooms might be needed, depending on the magnitude of patient- days of case
s of suspected or confirmed TB disease. Additional AII rooms might be considered
if options are limited for transferring patients with suspected or confirmed TB
disease to other settings with AII rooms. 9. Determine the types of environment
al controls needed other than AII rooms (see TB Airborne Precautions). 10. Deter
mine which HCWs need to be included in the respiratory protection program.
11. Conduct periodic reassessments (annually, if possible) to ensure 1.- proper
implementation of the TB infection control plan, 2.- prompt detection and evalua
tion of suspected TB cases, 3.- prompt initiation of airborne precautions of sus
pected infectious TB cases, 4.- recommended medical management of patients with
suspected or confirmed TB disease (31), 5.- functional environmental controls, 6
.- implementation of the respiratory protection program, and 7.- ongoing HCW tra
ining and education regarding TB. 12. Recognize and correct lapses in infection
control. TB Screening Risk Classifications -The three TB screening risk classifi
cations are low risk, medium risk, and potential ongoing transmission. The class
ification of low risk should be applied to settings in which persons with TB dis
ease are not expected to be encountered, and, therefore, exposure to M. tubercul
osis is unlikely. This classification should also be
applied to HCWs who will never be exposed to persons with TB disease or to clini
cal specimens that might contain M. tuberculosis. -The classification of medium
risk should be applied to settings in which the risk assessment has determined t
hat HCWs will or will possibly be exposed to persons with TB disease or to clini
cal specimens that might contain M. tuberculosis. -The classification of potenti
al ongoing transmission should be temporarily applied to any setting (or group o
f HCWs) if evidence suggestive of person to-person (e.g., patient-to- patient, p
atient-to-HCW, HCW to-patient, or HCW to-HCW) transmission of M. tuberculosis ha
s occurred in the setting during the preceding year. Evidence of person to-perso
n transmission of M. tuberculosis includes 1) clusters of TST or BAMT conversion
s, 2) HCW with confirmed TB disease, 3) increased rates of TST or BAMT conversio
ns, 4) unrecognized TB disease in patients or HCWs, or 5) recognition
of an identical strain of M. tuberculosis in patients or HCWs with TB disease id
entified by deoxyribonucleic acid (DNA) fingerprinting. If uncertainty exists re
garding whether to classify a setting as low risk or medium risk, the setting ty
pically should be classified as medium risk. TB Screening Procedures for Setting
s (or HCWs) Classified as Potential Ongoing Transmission -Testing for infection
with M. tuberculosis might need to be performed every 8-10 weeks until lapses in
infection control have been corrected, and no additional evidence of ongoing tr
ansmission is apparent. -The classification of potential ongoing transmission sh
ould be used as a temporary classification only. It warrants immediate investiga
tion and corrective steps. After a determination that ongoing transmission has c
eased, the setting should be reclassified
as medium risk. Maintaining the classification of medium risk for at least 1 yea
r is recommended. 3) Summerlin Hospital Medical Center Policies and Procedures -
TB Exposure Control Plan Page 4 D. Initial and Periodic Risk Assessment 3. Risk
Evaluation of personnel will be done initially on hire and within every 365 day
s hereinafter, or in the event of an exposure.

Issued

2014-04-09 00:00:00

Abate by

2014-05-12 00:00:00

Penalty

Initial $6300.00 · Current $0.00 Reduced

General-duty citation text

Nevada Revised Statute 618.375(1): Duties of employers. Every employer shall fur
nish employment and a place of employment which are free from recognized hazards
that are causing or are likely to cause death or serious physical harm to his o
r her employees: 1)Prior to this inspection, Summerlin Hospital Medical Center's
Tuberculosis
(TB) Exposure Control Plan has not been reevaluated since the occurrence of a si
gnificant workplace exposure to Mycobacterium tuberculosis. In 2013, at least tw
o patients with unrecognized tuberculosis (TB) disease were admitted into the ho
spital and cared for by staff, exposing employees to Mycobacterium tuberculosis
and subsequently causing 20 employees to contract tuberculosis and exhibit eithe
r active or latent forms of the infection. A reevaluation is needed to identify
and correct possible problems in TB infection control. 2)Prior to this inspectio
n, there was no requirement in Summerlin Hospital Medical Center's Tuberculosis
(TB) Exposure Control Plan for annual reevaluations, and the program was not ree
valuated on an annual basis. A yearly reevaluation is needed to identify and cor
rect possible problems in TB infection control. A feasible and accepted abatemen
t method for reducing these hazards, as recommended by the Center for Disease Co
ntrol and Prevention (CDC), is to follow their 2005 "Guidelines for the Transmis
sion of Mycobacterium tuberculosis in Health Care
Facilities" and review the TB infection control plan according to the Guideline'
s Evaluation of TB Infection Control Procedures and Identification of Problems s
ection. The facility's TB Exposure Control Plan should be revised to reflect the
implementation of this. References: 1) Nevada Administrative Code 441A.200: Inf
ectious Diseases. List of adopted recommendations, guidelines and publications;
review of revision or amendment of adopted recommendation, guideline or publicat
ion: The following recommendations, guidelines and publications are adopted by r
eference: (h) The recommendations of the Centers for Disease Control and Prevent
ion for preventing the transmission of tuberculosis in facilities providing heal
th care set forth in "Guidelines for Preventing the Transmission of Mycobacteriu
m tuberculosis in Health-Care Settings,
2005," Morbidity and Mortality Weekly Report[54(RR17):1-141, December 30, 2005].
2) "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in
Health Care Facilities," 2005. Centers for Disease Control and Prevention (CDC)
, MMWR December 30, 2005/Vol. 54/No. RR-17. TB Infection-Control Program for Set
tings in Which Patients with Suspected or Confirmed TB Disease Are Expected To B
e Encountered The TB infection control program should consist of administrative
controls, environmental controls, and a respiratory protection program. Every se
tting in which services are provided to persons who have suspected or confirmed
infectious TB disease, including laboratories and nontraditional facility based
settings, should have a TB infection-control plan. The following steps should be
taken to establish a TB infection control program in these settings:
2. Develop a written TB infection control plan that outlines a protocol for the
prompt recognition and initiation of airborne precautions of persons with suspec
ted or con-firmed TB disease, and update it annually. Evaluation of TB Infection
Control Procedures and Identification of Problems Annual evaluations of the TB
infection control plan are needed to ensure the proper implementation of the pla
n and to recognize and correct lapses in infection control. Previous hospital ad
missions and outpatient visits of patients with TB disease should be noted befor
e the onset of TB symptoms. Medical records of a sample of patients with suspect
ed and confirmed TB disease who were treated or examined at the setting should b
e reviewed to identify possible problems in TB infection control. The review sho
uld be based on the factors listed on the TB Risk Assessment Worksheet (Appendix
B).
*Time interval from suspicion of TB until initiation of airborne precautions and
antituberculosis treatment to: - suspicion of TB disease and patient triage to
proper AII room or referral center for settings that do not provide care for pat
ients with suspected or confirmed TB disease; - admission until TB disease was s
uspected; - admission until medical evaluation for TB disease was performed; - a
dmission until specimens for AFB (acid-fast bacilli is a laboratory test that in
volves microscopic examination of a stained smear of a patient specimen (usually
sputum) to determine if mycobacteria are present) smears and polymerase chain r
eaction (PCR)- based nucleic acid amplification (NAA) tests for M. tuberculosis
were ordered; - admission until specimens for mycobacterial culture were ordered
; - ordering of AFB smears, NAA tests, and mycobacterial culture until specimens
were
collected; - collection of specimens until performance and AFB smear results wer
e reported; - collection of specimens until performance and culture results were
reported; - collection of specimens until species identification was reported;
- collection of specimens until drug-susceptibility test results were reported;
- admission until airborne precautions were initiated; and - admission until ant
ituberculosis treatment was initiated. *Duration of airborne precautions. *Measu
rement of meeting criteria for discontinuing airborne precautions. Certain patie
nts might be correctly discharged from an AII room to home. *Patient history of
previous admission. *Adequacy of antituberculosis treatment regimens. *Adequacy
of procedures for collection of follow-up sputum specimens. *Adequacy of dischar
ge planning. *Number of visits to outpatient setting from the start of symptoms
until TB disease was suspected (for outpatient settings).
Work practices related to airborne precautions should be observed to determine i
f employers are enforcing all practices, if HCWs are adhering to infection contr
ol policies, and if patient adherence to airborne precautions is being enforced.
Data from the case reviews and observations in the annual risk assessment shoul
d be used to determine the need to modify 1) protocols for identifying and initi
ating prompt airborne precautions for patients with suspected or confirmed infec
tious TB disease, 2) protocols for patient management, 3) laboratory procedures,
or 4) TB training and education programs for HCWs.

Issued

2014-04-09 00:00:00

Abate by

2014-05-12 00:00:00

Penalty

Initial $6300.00 · Current $0.00 Reduced

General-duty citation text

Nevada Revised Statute 618.375(1): Duties of employers. Every employer shall fur
nish employment and a place of employment which are free from recognized hazards
that are causing or are likely to cause death or serious physical harm to his o
r her employees: Prior to this inspection, Summerlin Hospital Medical Center did
not have procedures
in place to ensure that employees who have been directly exposed to patients wit
h tuberculosis (TB) disease are screened for the infection as soon as possible a
fter exposure to Mycobacterium tuberculosis, or are provided follow up screening
s if needed. In 2013, at least two patients with unrecognized tuberculosis disea
se were admitted into the hospital and cared for by staff, exposing employees to
Mycobacterium tuberculosis and subsequently causing 20 employees to contract tu
berculosis and exhibit either active or latent forms of the infection. At least
one hospital employee who had direct contact with at least one of the infected p
atients was not given an initial TB screening until 8 weeks after the exposure.
A feasible and accepted abatement method for reducing this hazard, as recommende
d by the Center for Disease Control and Prevention (CDC), is to follow their 200
5 "Guidelines for the Transmission of Mycobacterium tuberculosis in Health Care
Facilities" and institute proper procedures according to the Guideline's Problem
Evaluation and Contact Investigation sections. The facility's TB Exposure Contr
ol Plan should be revised to reflect the implementation of this. References: 1)
Nevada Administrative Code 441A.200: Infectious Diseases. List of adopted recomm
endations, guidelines and publications; review of revision or amendment of adopt
ed recommendation, guideline or publication: The following recommendations, guid
elines and publications are adopted by reference: (h) The recommendations of the
Centers for Disease Control and Prevention for preventing the transmission of t
uberculosis in facilities providing health care set forth in "Guidelines for Pre
venting the Transmission of Mycobacterium tuberculosis in Health-Care Settings,
2005," Morbidity and Mortality Weekly Report[54(RR17):1-141, December 30, 2005].
2) "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in
Health Care Facilities," 2005. Centers for Disease Control and Prevention (CDC),
MMWR December 30, 2005/Vol. 54/No. RR-17. Investigating Conversions in Test Res
ults for M. tuberculosis Infection in HCWs: Known Source in the Health-Care Sett
ing An investigation of a test conversion should be performed in collaboration w
ith the local or state health department. If a conversion in an HCW is detected
and the HCW's history does not document exposure outside the health-care setting
but does identify a probable source in the setting, the following steps should
be taken: 1) identify and evaluate close contacts of the suspected source case,
including other patients and visitors; 2) determine possible reasons for the exp
osure; 3) implement interventions to correct the
lapse(s) ininfection control; and 4) immediately screen HCWs and patients if the
y were close contacts to the source case. For exposed HCWs and patients in a set
ting that has chosen to screen for infection with M. tuberculosis by using the T
ST, the following steps should be taken: - administer a symptom screen; - admini
ster a TST to those who had previously negative TST results; baseline two-step T
ST should not be performed in contact investigations; - repeat the TST and sympt
om screen 8-10 weeks after the end of exposure, if the initial TST result is neg
ative (33); - administer a symptom screen, if the baseline TST result is positiv
e; - promptly evaluate (including a chest radiograph) the exposed person for TB
disease, if the symptom screen or the initial or 8-10-week follow-up TST result
is positive; and - conduct additional medical and diagnostic evaluation (which i
ncludes a judgment about the extent of exposure) for LTBI, if TB disease is excl
uded.
If no additional conversions in the test results for M. tuberculosis infection a
re detected in the follow-up testing, terminate the investigation. If additional
conversions in the tests for M. tuberculosis infection are detected in the foll
ow-up testing, transmission might still be occurring, and additional actions are
needed: 1) implement a classification of potential ongoing transmission for the
specific setting or group of HCWs; 2) the initial cluster of test conversions s
hould be reported promptly to the local or state health department; 3) possible
reasons for exposure and transmission should be reassessed and 4) the degree of
adherence to the interventions implemented should be evaluated. Testing for M. t
uberculosis infection should be repeated 8-10 weeks after the end of exposure fo
r HCW contacts who previously had negative test results, and the circle of conta
cts should be expanded to include other persons who might have been exposed. If
no additional TST conversions are detected on the second round of follow-up test
ing, terminate the investigation. If additional TST conversions are detected on
the second round of follow-up testing, maintain a classification of potential on
going transmission and consult the local or state health department or other per
sons with expertise in TB infection control for assistance. The classification o
f potential ongoing transmission should be used as a temporary classification on
ly. This classification warrants immediate investigation and corrective steps. A
fter determination has been made that ongoing transmission has ceased, the setti
ng should be reclassified as medium risk. Maintaining the classification of medi
um risk for at least 1 year is recommended. Contact Investigations The primary g
oal of contact investigations is to identify secondary cases of
TB disease and LTBI among contacts so that therapy can be initiated as needed (2
63-265). Contact investigations should be collaboratively conducted by both infe
ction control personnel and local TB control program personnel. Initiating a Con
tact Investigation A contact investigation should be initiated when 1) a person
with TB disease has been examined at a health-care setting, and TB disease was n
ot diagnosed and reported quickly, resulting in failure to apply recommended TB
infection controls; 2) environmental controls or other infection control measure
s have malfunctioned while a person with TB disease was in the setting; or 3) an
HCW develops TB disease and exposes other persons in the setting. As soon as TB
disease is diagnosed or a problem is recognized, standard public health practic
e should be implemented to prioritize the identification of other patients,
HCWs, and visitors who might have been exposed to the index case before TB infec
tion control measures were correctly applied (52). Visitors of these patients mi
ght also be contacts or the source case. The following activities should be impl
emented in collaboration with or by the local or state health department (34,266
): 1) interview the index case and all persons who might have been exposed; 2) r
eview the medical records of the index case; 3) determine the exposure sites (i.
e., where the index case lived, worked, visited, or was hospitalized before bein
g placed under airborne precautions); and 4) determine the infectious period of
the index case, which is the period during which a person with TB disease is con
sidered contagious and most capable of transmitting M. tuberculosis to others. F
or programmatic purposes, for patients with positive AFB sputum smear results,
the infectious period can be considered to begin 3 months before the collection
date of the first positive AFB sputum smear result or the symptom onset date (wh
ichever is earlier). The end of the infectious period is the date the patient is
placed under airborne precautions or the date of collection of the first of con
sistently negative AFB sputum smear results (whichever is earlier). For patients
with negative AFB sputum smear results, the infectious period can begin 1 month
before the symptom onset date and end when the patient is placed under airborne
precautions. The exposure period, the time during which a person shared the sam
e air space with a person with TB disease for each contact, should be determined
as well as whether transmission occurred from the index patient to persons with
whom the index patient had intense contact. In addition, the following should b
e determined: 1) intensity of the
exposure based on proximity, 2) overlap with the infectious period of the index
case, 3) duration of exposure, 4) presence or absence of infection control measu
res, 5) infectiousness of the index case, 6) performance of procedures that coul
d increase the risk for transmission during contact (e.g., sputum induction, bro
nchoscopy, and airway suction), and 7) the exposed cohort of contacts for TB scr
eening. The most intensely exposed HCWs and patients should be screened as soon
as possible after exposure to M. tuberculosis has occurred and 8-10 weeks after
the end of exposure if the initial TST result is negative. Close contacts should
be the highest priority for screening. For HCWs and patients who are presumed t
o have been exposed in a setting that screens for infection with M. tuberculosis
using the TST, the following activities should be implemented: - performing a s
ymptom screen; - administering a TST to those who previously had negative TST re
sults;
- repeating the TST and symptom screen 8-10 weeks after the end of exposure, if
the initial TST result is negative; - promptly evaluating the HCW for TB disease
, including performing a chest radiograph, if the symptom screen or the initial
or 8-10-week follow-up TST result is positive; and - providing additional medica
l and diagnostic evaluation for LTBI, including determining the extent of exposu
re, if TB disease is excluded. For HCWs and patients who are presumed to have be
en exposed in a setting that screens for infection with M. tuberculosis using th
e BAMT (A general term to refer to recently developed in vitro diagnostic tests
that assess for the tuberculosis (BAMT) presence of infection with M. tuberculos
is. In the United States, the currently available test is QuantiFERON.-TB Gold t
est (QFT-G).), the following activities should be implemented (see Supplement, S
urveillance and Detection of M. tuberculosis Infections in Health Care
Settings). If the most intensely exposed persons have test conversions or positi
ve test results for M. tuberculosis infection in the absence of a previous histo
ry of a positive test result or TB disease, expand the investigation to evaluate
persons with whom the index patient had less contact. If the evaluation of the
most intensely exposed contacts yields no evidence of transmission, expanding te
sting to others is not necessary. Exposed persons with documented previously pos
itive test results for M. tuberculosis infection do not require either repeat te
sting for M. tuberculosis infection or a chest radio-graph (unless they are immu
nocompromised or otherwise at high risk for TB disease), but they should receive
a symptom screen. If the person has symptoms of TB disease, 1) record the sympt
oms in the HCW's medical chart or employee health record, 2) perform a chest rad
iograph, 3) perform a full medical evaluation, and 4) obtain sputum samples for
smear and culture, if indicated.
The setting should determine the reason(s) that a TB diagnosis or initiation of
airborne precautions was delayed or procedures failed, which led to transmission
of M. tuberculosis in the setting. Reasons and corrective actions taken should
be recorded, including changes in policies, procedures, and TB training and educ
ation practices.

Issued

2014-04-09 00:00:00

Abate by

2014-05-12 00:00:00

Penalty

Initial $6300.00 · Current $0.00 Reduced

General-duty citation text

Nevada Revised Statute 618.375(1): Duties of employers. Every employer shall fur
nish employment and a place of employment which are free from recognized hazards
that are causing or are likely to cause death or serious physical harm to his o
r her employees: Prior to this inspection, Summerlin Hospital Medical Center's T
uberculosis (TB) Control Plan did not require prompt evaluations for all employe
es whose TB screening tests converted from negative to positive after exposure t
o M. tuberculosis. In 2013, at least two patients with unrecognized tuberculosis
disease were admitted
into the hospital and cared for by staff, exposing employees to Mycobacterium tu
berculosis and subsequently causing 20 employees to contract tuberculosis and ex
hibit either active or latent forms of the infection. At least eight hospital em
ployees who had converted as a result of this workplace exposure had to wait sev
en days or longer to receive a chest x-ray to rule out active tuberculosis. A fe
asible and accepted abatement method for reducing this hazard, as recommended by
the Center for Disease Control and Prevention (CDC), is to follow their 2005 "G
uidelines for the Transmission of Mycobacterium tuberculosis in Health Care Faci
lities" and promptly evaluate employees who converted to a positive tuberculosis
screening test result with a chest radiograph. The facility's TB Exposure Contr
ol Plan should be revised to reflect the implementation of this. References:
1) Nevada Administrative Code 441A.200: Infectious Diseases. List of adopted rec
ommendations, guidelines and publications; review of revision or amendment of ad
opted recommendation, guideline or publication: The following recommendations, g
uidelines and publications are adopted by reference: (h) The recommendations of
the Centers for Disease Control and Prevention for preventing the transmission o
f tuberculosis in facilities providing health care set forth in "Guidelines for
Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Setting
s, 2005," Morbidity and Mortality Weekly Report[54(RR17):1-141, December 30, 200
5]. 2) "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis
in Health Care Facilities," 2005. Centers for Disease Control and Prevention (C
DC), MMWR December 30, 2005/Vol. 54/No. RR-17.
Investigating Conversions in Test Results for M. tuberculosis Infection in HCWs:
Known Source in the Health-Care Setting An investigation of a test conversion s
hould be performed in collaboration with the local or state health department. I
f a conversion in an HCW is detected and the HCW's history does not document exp
osure outside the health-care setting but does identify a probable source in the
setting, the following steps should be taken: 1) identify and evaluate close co
ntacts of the suspected source case, including other patients and visitors; 2) d
etermine possible reasons for the exposure; 3) implement interventions to correc
t the lapse(s) in infection control; and 4) immediately screen HCWs and patients
if they were closecontacts to the source case. For exposed HCWs and patients in
a setting that has chosen to screen for infection with M. tuberculosis by using
the TST, the following steps should be taken:
- administer a symptom screen; - administer a TST to those who had previously ne
gative TST results; baseline two-step TST should not be performed in contact inv
estigations; - repeat the TST and symptom screen 8-10 weeks after the end of exp
osure, if the initial TST result is negative (33); o administer a symptom screen
, if the baseline TST result is positive; - promptly evaluate (including a chest
radiograph) the exposed person for TB disease, if the symptom screen or the ini
tial or 8-10-week follow-up TST result is positive; and - conduct additional med
ical and diagnostic evaluation (which includes a judgment about the extent of ex
posure) for LTBI, if TB disease is excluded.

Issued

2014-04-09 00:00:00

Abate by

2014-05-12 00:00:00

Penalty

Initial $6300.00 · Current $0.00 Reduced

General-duty citation text

Nevada Revised Statute 618.375(1): Duties of employers. Every employer shall fur
nish employment and a place of employment which are free from recognized hazards
that are causing or are likely to cause death or serious physical harm to his o
r her employees:
1)Summerlin Hospital Medical Center does not conduct proper diagnostic measures
for patients who display signs of tuberculosis (TB). In 2013, at least two patie
nts with unrecognized TB disease were admitted into the hospital and cared for b
y hospital staff, one of whom displayed signs of tuberculosis, presenting with m
iliary TB with pulmonary involvement, but a sputum examination was never conduct
ed. Employees were exposed to Mycobacterium tuberculosis, subsequently causing 2
0 employees to contract tuberculosis and exhibit either active or latent forms o
f the infection. 2)Prior to this inspection, Summerlin Hospital Medical Center's
TB Exposure Control Plan did not include all the significant symptoms that are
indicative of a tuberculosis diagnosis, nor did it require the administration of
subsequent diagnostic measures, such as a sputum culture, in the presence of th
ese symptoms. A feasible and accepted abatement method for reducing these hazard
s, as recommended by the Center for Disease Control and Prevention (CDC), is to
follow their 2005
"Guidelines for the Transmission of Mycobacterium tuberculosis in Health Care Fa
cilities" and conduct proper diagnostic measures for patients with signs of lung
infection and chest radiograph findings suggestive of TB disease. The facility'
s TB Exposure Control Plan should be revised to reflect the implementation of th
is. References: 1) Nevada Administrative Code 441A.200: Infectious Diseases. Lis
t of adopted recommendations, guidelines and publications; review of revision or
amendment of adopted recommendation, guideline or publication: The following re
commendations, guidelines and publications are adopted by reference: (h) The rec
ommendations of the Centers for Disease Control and Prevention for preventing th
e transmission of tuberculosis in facilities providing health care set forth in
"Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Hea
lth-Care Settings,
2005," Morbidity and Mortality Weekly Report[54(RR17):1-141, December 30, 2005].
2) "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in
Health Care Facilities," 2005. Centers for Disease Control and Prevention (CDC)
, MMWR December 30, 2005/Vol. 54/No. RR-17. Prompt Triage A diagnosis of respira
tory TB disease should be considered for any patient with symptoms or signs of i
nfection in the lung, pleura, or airways (including larynx), including coughing
for more than 3 weeks, loss of appetite, unexplained weight loss, night sweats,
bloody sputum or hemoptysis, hoarseness, fever, fatigue, or chest pain.The index
of suspicion for TB disease will vary by geographic area and will depend on the
population served by the setting. The index of suspicion should be substantiall
y high for geographic areas and groups of patients characterized by high TB inci
dence
(26). Clinical Diagnosis A complete medical history should be obtained, includin
g symptoms of TB disease, previous TB disease and treatment, previous history of
infection with M. tuberculosis, and previous treatment of LTBI or exposure to p
ersons with TB disease. A physical examination should be performed, including ch
est radiograph, microscopic examination, culture, and, when indicated, NAA testi
ng of sputum (39,53,125,126). If possible, sputum induction with aerosol inhalat
ion is preferred, particularly when the patient cannot produce sputum. Gastric a
spiration might be necessary for those patients, particularly children, who cann
ot produce sputum, even with aerosol inhalation (127- 130). Bronchoscopy might b
e needed for specimen collection, especially if sputum specimens have been nondi
agnostic and doubt exists as to the diagnosis (90,111,127,128,131-134).
All patients with suspected or confirmed infectious TB disease should be placed
under airborne precautions until they have been determined to be noninfectious (
see Supplement, Estimating the Infectiousness of a TB Patient). Adult and adoles
cent patients who might be infectious include persons who are coughing; have cav
itation on chest radiograph; have positive AFB sputum smear results; have respir
atory tract disease with involvement of the lung, pleura or airways, including l
arynx, who fail to cover the mouth and nose when coughing; are not on antituberc
ulosis treatment or are on incorrect antituberculosis treatment; or are undergoi
ng cough-inducing or aerosol-generating procedures (e.g., sputum induction, bron
choscopy, and airway suction) (30,135). Chest Radiography Chest radiographic abn
ormalities can suggest pulmonary TB disease. Radiographic
abnormalities that are consistent with pulmonary TB disease include upper-lobe i
nfiltration, cavitation, and effusion. Infiltrates can be patchy or nodular and
observed in the apical (in the top part of the lungs) or subapical posterior upp
er lobes or superior segment of the lower lobes in the lungs. Evaluation of Sput
um Samples Sputum examination is a critical diagnostic procedure for pulmonary T
B disease (30) and is indicated for the following persons: - anyone suspected of
having pulmonary or laryngeal TB disease; - persons with chest radiograph findi
ngs consistent with TB disease (current, previous, or healed TB); - persons with
symptoms of infection in the lung, pleura, or airways, including larynx; - HIV
infected persons with any respiratory symptoms or signs, regardless of chest rad
iograph findings; and - persons suspected of having pulmonary TB disease for who
m bronchoscopy is planned.

Issued

2014-04-09 00:00:00

Abate by

2014-05-12 00:00:00

Penalty

Initial $6300.00 · Current $0.00 Reduced

General-duty citation text

Nevada Revised Statute 618.375(1): Duties of employers. Every employer shall fur
nish employment and a place of employment which are free from recognized hazards
that are causing or are likely to cause death or serious physical harm to his o
r her employees: 1)Summerlin Hospital Medical Center does not initiate airborne
precautions for patients who display signs of tuberculosis (TB). In 2013, at lea
st two patients with unrecognized TB disease were admitted into the hospital and
cared for by hospital staff, one of whom displayed signs of tuberculosis, prese
nting with miliary TB with pulmonary involvement, airborne precautions were neve
r initiated. Employees were exposed to Mycobacterium tuberculosis, subsequently
causing 20 employees to contract tuberculosis and exhibit either active or laten
t forms of the infection. 2)Prior to this inspection, Summerlin Hospital Medical
Center's TB Exposure Control Plan did not require initiation of airborne precau
tions for all inpatients who exhibit signs or symptoms of tuberculosis (TB) dise
ase. The
plan only addressed the institution of airborne precautions for patients that ar
e known or suspected in the Emergency Room and Admitting Area. The TB Exposure C
ontrol Plan also did not specify persons authorized to initiate and discontinue
airborne precautions. A feasible and accepted abatement method for reducing thes
e hazards, as recommended by the Center for Disease Control and Prevention (CDC)
, is to follow their 2005 "Guidelines for the Transmission of Mycobacterium tube
rculosis in Health Care Facilities" and initiate airborne precautions for patien
ts exhibiting signs or symptoms indicative of TB disease. The facility's TB Expo
sure Control Plan should be revised to reflect the implementation of this. Refer
ences: 1) Nevada Administrative Code 441A.200: Infectious Diseases. List of adop
ted recommendations, guidelines and publications; review of revision
or amendment of adopted recommendation, guideline or publication: The following
recommendations, guidelines and publications are adopted by reference: (h) The r
ecommendations of the Centers for Disease Control and Prevention for preventing
the transmission of tuberculosis in facilities providing health care set forth i
n "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in H
ealth-Care Settings, 2005," Morbidity and Mortality Weekly Report[54(RR17):1-141
, December 30, 2005]. 2) "Guidelines for Preventing the Transmission of Mycobact
erium tuberculosis in Health Care Facilities," 2005. Centers for Disease Control
and Prevention (CDC), MMWR December 30, 2005/Vol. 54/No. RR-17. TB Airborne Pre
cautions Within health-care settings, TB airborne precautions should be initiate
d for any patient who has symptoms or signs of TB disease, or who has documented
infectious TB
disease and has not completed antituberculosis treatment. TB Airborne Precaution
s for Settings in Which Patients with Suspected or Confirmed TB Disease Are Expe
cted To Be Encountered Settings that plan to evaluate and manage patients with T
B disease should have at least one AII room or enclosure that meets AII requirem
ents (see Environmental Controls; and Supplement, Environmental Controls). These
settings should develop written policies that specify 1) indications for airbor
ne precautions, 2) persons authorized to initiate and discontinue airborne preca
utions, 3) specific airborne precautions, 4) AII room- monitoring procedures, 5)
procedures for managing patients who do not adhere to airborne precautions, and
6) criteria for discontinuing airborne precautions.