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Based on policy review, medical record review, document review and interview, staff did not ensure Hepatitis B positive (HBV+) patients or patients with an unknown status are not dialyzed in the inpatient unit with other patients per facility policy. Failure to follow facility infection control policy has the potential to result in disease transmission.

Findings include:

Review of policy "Hepatitis Screening" last reviewed 09/2015 revealed all new acute patients will have a Hepatitis B profile drawn either prior to or at first hemodialysis session. All hospitalized chronic patients must have a current (within 1 month) Hepatitis B surface antigen. Until hepatitis B antigen results are known, patients will not be dialyzed in the inpatient unit. Hemodialysis machines used for patients who are Hepatitis B antigen positive (HBV+) or those whose Hepatitis status is unknown shall be bleached and heat disinfected after each use. All patients that exhibit a HBV+ will not be dialyzed in the inpatient unit. They will require a private room and have a designated hemodialysis machine assigned to them. These machines shall be bleached and heat disinfected after each treatment and before returning to service.

Medical record review from 06/30/17 to 07/05/17 revealed documentation by multiple physicians indicating Patient #1 was HBV+. Lab results dated 11/18/16 and 07/06/17 confirm HBV+ status.

Review of laboratory results revealed the following patients are HBV susceptible and do not have sufficient surface antibody levels to achieve immunity to the virus:
- Patient #2: On 07/01/17 HBV- and on 07/11/17 HBV- but surface antibodies are <3.
- Patient #4: On 07/01/17 HBV- and on 07/11/17 HBV- but surface antibodies are <4.
- Patient #5: On 07/01/17 HBV- and on 07/08/17 HBV- but surface antibodies are <3.
- Patient #6: On 07/05/17 HBV- and on 07/06/17 HBV- but surface antibodies are <3.

Review of the inpatient dialysis patient schedule and dialysis flow sheets dated 07/06/17 revealed Patient #1 (HBV+) had a hemodialysis treatment initiated at 09:20 AM at Station #6 on Machine #54 with the treatment completed at 11:30 AM. Hemodialysis treatment was initiated for Patient #2 (HBV susceptible) at 03:17 PM at Station #6 on the same machine as Patient #1, Machine #54. Treatment was completed at 06:00 PM. Additionally, Patient #4 was dialyzed on Machine #57 from 08:33 AM to 12:55 PM, Patient # 5 was dialyzed on Machine # 59 from 08:00 AM to 03:00 PM and Patient #6 was dialyzed on Machine #59 from 03:57 PM to 05:29 PM. Patient #2, 4, 5 and 6 are HBV susceptible.

Interview on 08/02/17 at 02:30 PM and 08/03/17 at 01:00 PM with Staff (J), RN revealed on 07/06/17 Patient #2 (HBV susceptible) received a hemodialysis treatment after Patient #1 (HBV+) on Machine #54. The machine was not bleached and heat disinfected after use by Patient #1.

Interview on 08/03/17 at 11:30 AM with Staff (T), RN indicated Patient #1's Hepatitis B status was unknown at the time of treatment (07/06/17) and the Hepatitis B testing was ordered. Staff (T) indicated Patient #1 should not have been dialyzed on the inpatient unit.