Cook Childrens Medical Center Dialysis Unit

“IC: HBV: TEST ALL,REV RESULTS/STATUS B4 ADMIT CFR(s): 494.30(a)(1)(i) Routine Testing for Hepatitis B The HBV serological status (i.e. HBsAg, total anti-HBc and anti-HBs) of all patients should be known before admission to the hemodialysis unit. Routinely test all patients [as required by the referenced schedule for routine testing for Hepatitis B Virus]. Promptly review results, and ensure that patients are managed appropriately based on their testing results. This Standard is not met as evidenced by: 30377 Based on record review, interview and facility policies and procedures the facility failed to routinely test all patients [as required by the referenced schedule for routine testing for Hepatitis B Virus]. [ HBV-Susceptible Patients ....Test susceptible patients monthly for HBsAg, including those who a) have not yet received hepatitis B vaccine, b) are in the process of being vaccinated, or c) have not adequately responded to vaccination. Note that, while the patient’s anti-HBs is <10 mIU/mL, he/she is considered susceptible to hepatitis B, and should be tested for HBsAg monthly]. Promptly review results and ensure that patients are managed appropriately based on their testing results ...This deficient practice has potential to cause harm to all patients and staff who have negative anti-HBs. Facility policy titled “Hepatitis Screening” date of issue 02/2024 states “ .....Hemodialysis patient’s should be screened for HBsAg prior to initiating dialysis, and then twice yearly. If HBsAg negative and non-responders to vaccine, screen monthly. The patient is than to be screened for HBsAg twice yearly. If negative, Hepatitis B series needs to be initiated or booster needs to be given ....” Findings included: Review of the Lab Result Summary to include Hepatitis Surveillances revealed the following patients with Hepatitis Surface AB (anti-HBs) with nonreactive results were missing monthly Hepatitis B antigens (HBsAg). P#5 Hepatitis Surface AB with nonreactive result on 01/01/2025 were missing monthly Hepatitis B Antigens for February 2025, March 2025, and April 2025. P#6 Hepatitis Surface AB with nonreactive result on 01/02/2025 were missing monthly Hepatitis B Antigens for February 2025, March 2025, and April 2025. P#7 Hepatitis Surface AB with nonreactive result on 01/01/2025 were missing monthly Hepatitis B Antigens for February 2025, March 2025, and April 2025. An interview conducted with (S#1) on 05/07/2025 at 1:45 p.m. following his own review of the findings revealed he was aware of the discrepancies found. S#1 stated that Hepatitis Surface AB (anti-HBs) was resulted as reactive and or nonreactive and no numerical number was resulted. S#1 stated that Hepatitis B Antigens (HBsAg) were drawn every 6 months and not monthly for those patients that have a nonreactive Hepatitis Surface AB (anti-HBs) result. At the time of the interview no evidence of compliance was presented where noncompliance was found.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 43999 Based on record review and interview, the Interdisciplinary Team (IDT) failed to ensure that the patient Plan of Care (POC) was completed by the team to include discussion of the content in the plan of care with the patient/patient’s legal representative. Findings included: Review of 6 out of 6 patients (patients #1,#2,#3, #4,#5& #6 ) electronic medical records (EMR ) POCs for December 2023 and January 2024 were incomplete. The Plans of Care did not include signatures from the IDT or the patient/patient’s legal representative to demonstrate discussion and participation in the POC. The above was confirmed by the Clinic Manager on March 5, 2024.”