Dci Cullman

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 41624 Based on observations, clinic policy and procedures, and interview, it was determined the clinic failed to ensure staff performed antisepsis over cannulation sites per policy. This deficient practice affected two of two observations for Access of (arteriovenous) Fistula or Graft for Initiation of Dialysis, including Patient Identifier (PI) # 11 and PI # 9, and had the potential to affect all patients dialyzing with an AVF/AVG at this clinic. Findings include: Clinic Policy: Vascular Access Disinfectant Policy Procedure Number: 804 Date Issued: 1/24/2024 Policy: ...4. All staff will adhere to contact and drying time per antiseptic. Procedure: Option 1 (preferred): Chlorhexidine (Brand names include ChloraPrep and Prevantics) ...Apply disinfectant by using a gentle, back and forth scrubbing motion for a total of 30 seconds. Allow area to dry completely... Clinic Policy: Cannulation of the AV Graft or established AV Fistula Procedure Number; 802 Date Issued: 5/18/2022 Procedure: ...7. Clean chosen cannulation sites with disinfectant in a circular motion working inward to outward...Allow disinfectant to dry. *NOTE* for disinfectant chlorhexadine, drying time 30 seconds. 1. An observation was conducted on 9/9/25 at 11:05 AM with Employee Identifier (EI) # 4, Certified Clinical Hemodialysis Technician (CCHT), performing access of AVF/AVG for initiation of dialysis at station 9 for PI # 11. EI # 4 cleansed the cannulation sites with a chloraprep swab for five seconds and allowed them to dry for 15 seconds. An interview was conducted on 9/11/25 at 2:00 PM with EI # 1, Nurse Manager, who confirmed the staff failed to follow the clinic policy for antisepsis. 2. An observation was conducted on 9/9/25 at 11:06 AM with EI # 4 performing access of AVF/AVG for initiation of dialysis at station 14 for PI # 9. EI # 4 utilized a Prevantics (chlorhexadine) swab to perform antisepsis over each cannulation site using a circular motion for four seconds over each site. EI # 4 then allowed the sites to dry for two seconds before cannulating (accessing) with the dialysis needles. EI # 4 failed to perform antisepsis for 30 seconds, and wait 30 seconds for the sites to dry before cannulating per clinic policy. An interview was conducted on 9/11/25 at 2:00 PM with EI # 1, who confirmed the CCHT failed to perform antisepsis per policy. 47295”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 41624 Based on observations, clinic policy and procedure, and staff interview, it was determined the clinic failed to ensure staff cleaned and disinfected the dialysis station between patients per policy. This deficient practice was observed in three of three observations for Cleaning and Disinfection of the Dialysis Station, and had the potential to affect all patients dialyzing at this clinic. Findings include: Clinic Policy: Routine Disinfection in the Hemodialysis Unit Procedure Number: 204 Date Issued: 8/19/2020 Supportive Data: ...Proper cleaning and disinfection of environmental surfaces (including patient chairs or bed surfaces, dialysis equipment surfaces, adjacent tables and work surfaces) must be performed between patient uses to prevent transmission of dangerous pathogens. Procedure: ...3. To clean the dialysis machine, start at the top of the machine. Ensure that all items from top to bottom are cleaned, including but not limited to: IV (intravenous) pole, stethoscope (if left on machine), prime bucket/container, all components of machine (i.e. air detector, heparin pump, blood pump doors, Hansen connector and tubing), blood pressure cuff and tubing, any concentrate containers, bottom, sides, shelf and back of machine. 4...Ensure all components of the chair are cleaned top to bottom including but not limited to...Side tables, remotes/call lights.. 1. An observation was conducted on 9/9/25 at 9:45 AM with Employee Identifier (EI) # 2, Registered Nurse (RN), for cleaning and disinfection of dialysis station 9. EI # 2 failed to disinfect the Hansen connectors, prime waste container, IV pole hooks, and the counters behind the station. An interview was conducted on 9/11/25 at 2:00 PM with EI # 1, Nurse Manager, who confirmed the RN did not follow the policy for cleaning and disinfection of the dialysis station. 2. An observation was conducted on 9/10/25 at 10:27 AM with EI # 3, Certified Clinical Hemodialysis Technician (CCHT), for cleaning and disinfection of dialysis station 6. EI # 3 failed to disinfect the upper portion of the IV pole and hooks, Hansen connectors, sides of the tables, nurse call bell, and the counter behind the station. An interview was conducted on 9/11/25 at 2:00 PM with EI # 1, who confirmed the CCHT did not follow the policy for cleaning and disinfection of the dialysis station. 3. An observation was conducted on 9/10/25 at 10:51 AM with EI # 3 for cleaning and disinfection of dialysis station 5. EI # 3 failed to disinfect the upper portion of the IV pole and hooks, Hansen connectors, the bottom half of the front of the dialysis machine, dialysate hoses, sides of the tables, and the counter behind the station. An interview was conducted on 9/11/25 at 2:00 PM with EI # 1, who confirmed the CCHT did not follow the policy for cleaning and disinfection of the dialysis station. 47295”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 41624 Based on observations, clinic policy and procedures, manufacturer’s directions for use (MDFU), and staff interview, it was determined the clinic failed to ensure: 1. Antisepsis was performed per clinic procedure and MDFU in two of two observations of Central Venous Catheter (CVC) Exit Site Care. 2. Disinfection of the CVC connections was performed per clinic procedure and MDFU in two of two observations of Discontinuation of Dialysis with a CVC. This deficient practice affected Patient Identifier (PI) # 1, PI # 7, PI # 10, and PI # 8, and had the potential to affect all patients dialyzing with a CVC at this clinic. Findings include: Clinic Policy: Dressing Change and Site Care for the CVC Using Chlorhexidine Gluconate Securement (CHG) Dressing Procedure Number: 701 Date Issued: 1/30/2018 Procedure: ...6. Clean exit site with disinfectant. Preferred is Chlorhexidine. Allow disinfectant to dry completely... Key Point: If using Chlorhexidine product (Chloroprep, Prevantics, etc.), manufacturer’s recommendations are to start at center of exit site and clean outward in a concentric circular motion, using repeated back and forth strokes.. Clinic Policy: Termination of Treatment with Catheter Procedure Number: 705 Date Issued: 9/21/2022 Procedure: ...18. Clean arterial and venous needle-less connector with an alcohol pad... BD (Becton Dickinson) Chloraprep Single Swabstick MDFU: Directions: ...Use repeated back and forth strokes for 30 seconds. Allow the area to air dry for approximately 30 seconds... PDI (Professional Disposables International) Prevantics MDFU: Directions: ...Apply swab to skin using repeated back and forth strokes for 15 seconds. Allow the prepped area to air dry for 30 seconds. 1. An observation was conducted on 9/9/25 at 10:00 AM with Employee Identifier (EI) # 2, Registered Nurse (RN), performing discontinuation of dialysis with a CVC for PI # 1 at station 2. The CVC connections were disinfected with Prevantics for approximately five seconds. EI # 2 failed to follow the Prevantics MDFU which state to scrub for 15 seconds. An interview was conducted on 9/11/25 at 2:00 PM with EI # 1, Nurse Manager, who confirmed the staff failed to disinfect the CVC connections per the MDFU. 2. An observation was conducted on 9/9/25 at 10:17 AM with EI # 2, RN, performing Discontinuation of Dialysis with CVC for PI # 7 at station 4. EI # 2 scrubbed the CVC arterial connection/hub for three seconds with a Prevantics swab, and immediately applied the sterile port cap. EI # 2 then scrubbed the venous connection/hub for one second utilizing another Prevantics swab and immediately applied the sterile port cap. EI # 2 failed to follow the MDFU to perform a 15 second scrub and allow it to air dry for 30 seconds. An interview was conducted on 9/11/25 at 2:00 PM with EI # 1, who confirmed the RN failed to disinfect the connections/hubs per the MDFU for Prevantics. 3. An observation was conducted on 9/9/25 at 11:39 AM with EI # 2, performing CVC exit site care for PI # 10 at station 1. The CVC exit site was cleansed with Prevantics for five seconds. It was then allowed to dry for ten seconds. EI # 2 failed to follow the Prevantics MDFU which state to scrub for 15 seconds and allow to dry for 30 seconds. An interview was conducted on 9/11/25 at 2:00 PM with EI # 1, who confirmed the staff failed to disinfect the exit site per the MDFU. 4. An observation was conducted on 9/9/25 at 11:47 AM with EI # 2 performing CVC Exit Site Care for PI # 8 at station 16. EI # 2 cleaned the exit site utilizing a Chloraprep swab for five seconds, allowed the site to air dry for 30 seconds, then applied a new dressing. EI # 2 failed to clean the site for 30 seconds before allowing it to air dry. An interview was conducted on 9/11/25 at 2:00 PM, with EI # 1, who confirmed the RN failed to clean the exit site per the MDFU for Chloraprep. 47295”