A condition that the Centers for Medicaid and Medicare Services laid out for the Dialysis Unit of the LBJ Hospital was that all suspected patients and staff be vaccinated for Hepatitis B.
According to a report by CMS of a revisit survey conducted last year of the LBJ Hospital some staff who were care givers for dialysis patients were Hepatitis B positive.
According to CMS 12 direct care givers were positive for Hepatitis antibody and the last known date in which they were tested was 2012.
CMS also found that four licensed nurses were negative for Hepatitis antibody and there were two registered nurses whose Hepatitis status was unknown because lab results were not found.
The agency recorded in their report that one nurse was seen administering care for a patient in the isolation room who was Hepatitis positive and the same nurse then cared for non Hepatitis positive patients.
This nurse was a new hire and according to CMS her Hepatitis status was not known as lab results for her were not found.
The CMS report said another nurse supervisor in charge of the infection control program had negative resulted for Hepatitis antibody.
But she received only two series of the Hepatitis vaccine.
When CMS interviewed the facility nurse manager and asked about this nurse, they were told that the nurse has completed the Hepatitis vaccination.
However there was no written history of when the vaccination was given and the lab results of the nurse’s Hepatitis test.
Yet the nurse was observed giving medicine to a Hepatitis positive patient in the isolation room.
CMS said there was no policy to handle issues of staff who claim to be vaccinated but the source documents were not obtainable.
There was also no system as to how the facility scheduled the Hepatitis vaccination to staff and susceptible patients.
CMS said the sum result of these practices is failure of the dialysis facility to provide care and service in accordance with regulatory requirements under patient assessment.
