HospitalInspections.org

Based on record review and interview, the facility failed to conduct an investigation for a reported Hepatitis B conversion. Citing 1 (#1) of 12 patients reviewed. These findings have the likelihood to cause harm to all patients receiving care at the facility.
Findings:
A review of a State of Texas Reportable incident report revealed Patient #1 had a Hepatitis B conversion. The report indicated that a Hepatitis B test was collected on 01/06/2016 the patient's first day back at the chronic dialysis unit. The results of the test was reported to the clinic on 01/14/2016 with a "Hepatitis B Surface AG Positive". The clinic reported that Patient #1 had surgery at Facility #16 on 12/24/2015 and had received blood transfusions on 12/24/2015 and 12/28/2015. Also, the patient was dialyzed in the acute dialysis center of Facility #16 on 12/26/2015, 12/28/2015, and 12/30/2015. A review of the dialysis's clinic laboratory reports revealed the patient's Hepatitis B antigen had been negative from admission to the clinic on March 2015 through December 7, 2015. The reports indicate the patient was also negative for antibodies. The report revealed that the Dialysis clinic had notified Facility #16.
A phone interview with Employee #8 (employee from the nephrologist office) on 02/23/2016 at 10:00 a.m. revealed he had been notified of the positive Hepatitis B results on 01/14/2016. Employee #8 stated, "I hand carried the laboratory report to hospital (Facility #16) and gave it to Staff #9 (Nurse Manager of the Hospital's Dialysis unit)." Also, Employee #8 stated, "Regional Director (#10) with the dialysis contractor's corporate office was present in the office during the discussion."
A phone interview with #10 on 02/23/2016 at 10:25 a.m. confirmed that he knew about the Hepatitis B conversion. Regional Director #10 stated, "I had left the follow up and reporting of the Hepatitis B event with Staff #9." Also, Regional Director (#10) stated, "Staff #9 had been terminated from employment within the last two weeks."
An interview with Staff #11 on 02/23/2016 at 11:30 a.m. confirmed there was no evidence through the quality improvement process that the hospital had conducted an investigation into the Hepatitis B conversion. Staff #11 stated, "Staff #9 never reported the event to Staff #11 who was the Director of Nursing Quality or to the Infection Control Department.
An interview with Staff #12 (Infection Control Practitioner) on 02/23/2016 at 11:45 a.m. confirmed she had no knowledge of the Hepatitis B conversion.
An interview with Staff #15 (Director of Laboratory) on 02/23/2016 at 11:50 a.m. confirmed she had no knowledge of the Hepatitis B conversion.
An interview with Staff #4 (Director of Nursing) on 02/23/2016 at 1:00 p.m. confirmed she had no knowledge of the Hepatitis B conversion.