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NYU WINTHROP HOSPITAL 259 FIRST STREET MINEOLA, NY 11501 Aug. 30, 2018
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on staff interview and document review, the facility failed to ensure that a patient with Hepatitis B surface Antigen (HBsAg) positive was isolated during hemodialysis treatment. Therefore other patients were exposed to the risk of infection. This was evident in four (4) of four (4) medical records reviewed. (Patient#1, 2, 3 & 4).


Findings include:


CDC "Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients" 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." And

"HBV-Infected Patients. To isolate HBsAg-positive patients, designate a separate room for their treatment and dedicate machines, equipment, instruments, supplies, and medications that will not be used by HBV-susceptible patients. Most importantly, staff members who are caring for HBsAg-positive patients should not care for susceptible patients at the same time, including during the period when dialysis is terminated on one patient and initiated on another".


Review of Facility Incident Reports for 2018, showed that 3 patients were potentially exposed to Hepatitis B virus between 5/30/18 to 6/1/18.

Review of medical record for Patient #1 identified: patient was transferred to this Facility on 5/29/18. The transferring hospital Summary documented that the patient was having hemodialysis and was diagnosed with Hepatitis B since 9/12/2011. The Facility identified the patient as unknown Hepatitis B status and on 5/30/18, Patient#1 was dialyzed in the Acute hemodialysis unit without any precautionary measures


On 5/31/18 at 7:26 AM, Patient #2 was dialyzed in the Acute hemodialysis unit using the same machine as Patient #1.

On 5/31/18 at 12:50PM, Patient #3 was dialyzed on the same hemodialysis machine as Patient #1.

On 6/01/18 at 7:49 AM, Patient #4 was dialyzed using the same machine as Patient #1.


During interview on 8/27/18 at 2:50PM, Staff A, Medical Director for Dialysis stated that Patient #1, Hepatitis B status was reviewed prior to the initiation of the first dialysis treatment, however "it means little," since the hospital has a system in place to conduct their own testing. He believes the hospitals testing is more reliable and the result is usually available in 2 to 3 hours. He further stated that the hemodialysis machines are cleaned after each patient using heat and chemical.

During interview on 8/28/18 2:20 PM Staff B, Nurse Manager stated that the dialysis unit did not make any attempt to contact the transferring hospital to confirm the Hepatitis status of Patient #1. Trying to contact outside facilities to confirm the hepatitis status of each patient prior to the first dialysis treatment "would be too much work," she said.


Review of the Hospital's Policy & Procedure titled "Management of the Hemodialysis Machine when Dialyzing Patients with Unknown or Positive B in Patient Dialysis Unit." effective 6/2018 states: Reactive Patients to HBsAG or HepB Core Antibody IGM, must be dialyzed in their private hospital room or an isolation room on their floor with a dedicated machine, supplies, equipment and instruments."

The Facility failed to implement this policy for a patient with a known HBV status.

The Policy does not contain directives for isolation (as recommended by CDC) of patient with unknown HBV status.