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Based on clinical record review, interview and policy review, for one of seven hemodialysis patients' reviewed (Patient #1), the facility failed to ensure that a comprehensive assessment of the patient's abnormal laboratory results were addressed prior to the initiation of dialysis. The finding includes the following:

a. Patient #1 was admitted to the facility on 6/5/17 and had a liver transplant on 6/7/17. The H&P indicated acute on chronic hepatitis B with cirrhosis. Review of the problem list included in part, diabetes mellitus, obesity, stroke, hypertension and acute hepatitis (4/30/17). The patient was being treated with Tenofovir and immunoglobulin.

Subsequent to surgery the patient developed an acute kidney injury (AKI), requiring hemodialysis. Review of the clinical record indicated that a Hepatitis B panel completed on 6/7/17 identified the patient had a positive surface antigen (reference range is a negative result) and <8 antibodies (goal >12). On 6/5/17 the Polymerase Chain Reaction (PCR) indicated that hepatitis B was detected in the blood with a viral count of 15200 IU/ml.

The patient started hemodialysis in the inpatient unit on 6/29/17. Review of the dialysis treatment flow sheet indicated that the patient was surface antigen negative and antibody positive. The patient received hemodialysis on 7/1/17, 7/3/17, 7/5/17, 7/7/17, and 7/10/17. Interview and review of the dialysis flow sheets with RN #1 on 7/25/17 at 10:00 AM indicated that prior to initiating dialysis staff ensure that the patient was surface antigen negative. The RN indicated that staff do not normally review all the Hepatitis labs, they just ensure that the patients are antigen negative prior to the initiation of the first dialysis treatment. RN #1 stated that since the patient was not on isolation the dialysis machine used had not been bleached after use.

Interview with Renal Fellow #2 on 7/25/17 stated on 7/12/17 he was new to the patient and upon review of the record identified a full Hepatitis screening inclusive of a PCR. Review of the PCR's obtained during the period of 6/5/17 through 7/19/17 identified that the patient had detectable levels of Hepatitis B in his/her blood.

Interview with MD #1 (Attending) on 7/25/17 at 1:15 PM stated that he knew the patient had Hepatitis B but felt that the patient had reactivated after his/her liver transplant and at the time of dialysis was surface antigen negative meeting the CDC criteria. MD #1 further stated that he did not look at the PCR until Renal Fellow #2 inquired what detectable meant. MD#1 indicated that at that time he contacted several colleagues and the Infectious Disease Chair with a decision made to isolate the patient. Interview with the Infectious Disease Chair on 7/25/17 at 1:50 PM stated that the patient had identifiable hepatitis B in his/her blood and should be dialyzed in isolation. The facility failed to ensure that the patient's lab results were comprehensively reviewed and/or when unsure of the meaning of a result that the appropriate consults were obtained for clarification prior to the initiation of dialysis.