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Based on observation, document review and interview, the facility failed to ensure that staff followed standards of practice for infection control to reduce the potential for transmission of infection.
(1) The hospital failed to ensure that staff followed standard infection control precautions when performing hemodialysis and caring for patients with contact and droplet precautions.
(2) The hospital failed to ensure that, the HBV status of all such patients be ascertained at the time of admission to the hospital, by either a written report from the referring center (including the most recent date testing was performed) or by a serologic test.

This lapse in infection control practice may have placed patients at risk for cross contamination of infections.


Findings related to #1 include:

During a tour of the dialysis room (Room 2FE-184) at approximately 11:38 AM on 2/23/2018, the following were observed:
(a) Two (2) patients were in the room, lying in beds. Two (2) signs were posted outside the room; one was for "Droplet Precaution" (used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing), and the other was "Contact Isolation." (used for infections, diseases, or germs that are spread by touching the patient or items in the room).

(b) Two hospital transporters (Staff A and B) were observed entering the room. They entered the room without following any required infection control precautions. The state surveyor stopped the two staff and asked them if they have information about the patient they were about to transport. They stated that they did not know about the patient status. At this point of time, the nurse who was in the room came to the door and instructed them to put on gowns, masks and gloves. The nurse, Staff C, stated that the transporting team should have had the information on their computer as it is available on their system. She then stated that one of the patients has VRE (Vancomycin resistant enterococcus) and the other patient has droplet precautions.

(c) The two (2) transporters then proceeded to move one patient from the innermost part of the room. In doing so they were observed; touching the bed of the other patient who was receiving hemodialysis at the time and moving the staff chair, the portable computer station, medical waste containers, blood pressure machine and overhead table without changing gloves.
Failure of the staff to change gloves and perform hand hygiene between touching patients or touching equipment can result in cross contamination.

(d) There were two cloth cubicle curtains that were wrapped around the mounts that attached the TV to the wall. The curtains were touching the patient oxygen tubing, the suction containers and tubes.

(e) There was a wire mesh cabinet in the room that housed clean dialysis supplies The items in the cabinet were not protected or covered.

Based on the above observations the facility staff did not follow Center for Disease Control (CDC) recommendation in: "MMWR Recommendations for Preventing the Spread of Vancomycin Resistance Recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC September 22, 1995 / 44(RR12);1-13," which states:

Infection Control Precautions for Outpatient Hemodialysis Settings Compared with Inpatient Hospital Settings;
"... For certain patients, including those infected or colonized with MRSA or VRE, contact precautions are used in the inpatient hospital setting. Contact precautions include a) placing the patient in a single room or with another patient infected or colonized with the same organism; b) using gloves whenever entering the patient's room; and c) using a gown when entering the patient's room if the potential exists for the worker's clothing to have substantial contact with the patient, environmental surfaces, or items in the patient's room. "


Findings related to #2 include:

Review of medical records revealed that the hospital performed hemodialysis on patients in Room 2FE-184 without knowing their Hepatitis B Virus (HBV) status (unknown status) and these patients were in the same room with other patients who may be susceptible. This practice is potential for transmission of HBV from patients of unknown status if they were found later to be HBV positive, to the other susceptible patients. This was identified for Patient's # 1, 2, 3, 4, 5, 6, 7, 8.

Examples included but were not limited to:
-On 12/6/2017, Patient #2 was dialyzed together with Patient #1, whose HBV status was not known until 1/2/2018.

-On 12/24/2017, Patient #4 was dialyzed together with Patient #3, whose HBV status was not known until 2/13/2018.

-On 1/5/2018, Patient #6 was dialyzed together with Patient #5, whose HBV status was not known until 2/26/2018.

-On 1/6/2018, Patient #8 was dialyzed together with Patient #7, whose HBV status was not known until
2/21/2018).

Review of hospital Policy Number: HD 303, last revised 8/2017, states: "a patient with the following results will be considered to have Hepatitis B unknown status:
(A) Hepatitis BsAg negative > 30 days with a negative or unknown Hepatitis BsAb result.
(B) No Hepatitis Ag result available."


During interview with the Staff D, Medical Director (MD), on 3/1/2018 at 1:45 PM, she stated that the practice of performing hemodialysis of patients with unknown HBV status in the same room as susceptible patients is safe and added that since the staff follow universal precautions, this is sufficient to prevent infection. The Medical Director also stated that the Dialysis Machines are disinfected with bleach after dialyzing patients with unknown status because the machine is exposed directly to the patient's blood which makes them more dangerous.

CDC MMWR (Morbidity and Mortality Weekly Report) April 27, 2001 / 50(RR05);1-43, states:

Hemodialysis in Acute-Care Settings. For patients with acute renal failure who receive hemodialysis in acute-care settings, Standard Precautions as applied in all health-care settings are sufficient to prevent transmission of bloodborne viruses. However, when chronic hemodialysis patients receive maintenance hemodialysis while hospitalized, infection control precautions specifically designed for chronic hemodialysis units (see Recommended Practices at a Glance) should be applied to these patients. If both acute and chronic renal failure patients receive hemodialysis in the same unit, these infection control precautions should be applied to all patients.
Regardless of where in the acute-care setting chronic hemodialysis patients receive dialysis, the HBsAg status of all such patients should be ascertained at the time of admission to the hospital, by either a written report from the referring center (including the most recent date testing was performed) or by a serologic test. The HBV serologic status should be prominently placed in patients' hospital records, and all health-care personnel assigned to these patients, as well as the infection control practitioner, should be aware of the patients' serologic status. While hospitalized, HBsAg-positive chronic hemodialysis patients should undergo dialysis in a separate room and use separate machines, equipment, instruments, supplies, and medications designated only for HBsAg-positive patients (see Prevention and Management of HBV Infection). While HBsAg-positive patients are receiving dialysis, staff members who are caring for them should not care for susceptible patients.





RE-VISIT AT NYP COLUMBIA UNIVERSITY DIALYSIS UNIT:
FROM: Elizabeth Jaiyesimi, RN
Hospital Nursing Services Consultant

DATE: April 30, 2018

RE: New York - Presbyterian Hospital

Allegation #: NY00217471 and follow-up visit for NY00215404 Plan of Correction Verification



Authorization was received from CMS on 4/4/18 to conduct a Federal Allegation survey for the following Conditions of Participation: Physical Environment and Infection Control.

The investigation included an unannounced on-site visit on 4/30/18, observations in patient care areas, medical record review, review of pertinent hospital documents and interviews with staff members and patients.


SURVEY ACTIVITIES/DOCUMENT REVIEW: (Alter depending on CoP reviewed)


- Tour and observations conducted in the Acute Dialysis Unit.

The unit was well apportioned with 7 stations divided by thick plexi -glass partition which were ceiling high. Cubicle curtains were available within each partition. There was an additional room for any patient who is determined to be Hepatitis B positive. There has not been any patient who is Hep. B positive in seven years. There is dedicated equipment in the room such as a phoenix meter but there was no dedicated dialysis machine. During interview, the nurse manager confirmed that they have 2 Hep B+ dedicated machines stored in the Main building across the street, accessible by corridors and elevators. The location of the stored machine was noted to be quite remote to the unit. Because of the low to no incidence of a Hep B + patient, the location of the stored equipment was not considered significant. A staff member was observed during a discontinuation of treatment procedure on a patient using the CDC Checklist #5 titled "Discontinuation of Dialysis and Post Dialysis access care for AV Fistula or Graft". The staff performance was less than perfect. The facility had just been recertified using similar checklist and had done well during the recertification. it was decided that because the staff was working with a patient prone to bleeding, his omission of the step in the procedure was not considered significant.
A review of the policy with the PSA Regulatory manager reveal that the omitted step was not covered in the policy and procedure submitted for review.

- Facility staff interviews.

On 4/30/18 at 2:30PM the PSA Regulatory manager stated that patients on infection control precautions are cohorted in rooms according to the organism in questions and are mostly in single rooms unless there is room shortages at which time curtains are drawn between patients and the same types of isolation precautions are placed together. The registered nurse in charge of the unit also stated the Hepatitis B status of any patient are always established before the patient is treated.
A review of the facility isolation precaution list titled " Active ED and In Patient Isolation Listing" reveal that patients are properly cohorted and the chance of the spread of infection from one patient to the other is maximally reduced at this location.

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