Endeavor Dialysis

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 49603 Based on observations, review of the facility policy, and interviews, it was determined the facility failed to ensure patients performed hand hygiene after holding access sites and prior to leaving the treatment area in two of two observations for discontinuation of dialysis and post dialysis access care for AVF/AVG (arteriovenous fistula/graft), including PI (Patient Identifier) # 12 and an unsampled patient observation. This had the potential to negatively affect all 59 patients who dialyze at the facility, staff, and visitors. Findings include: Facility Policy: Hand Hygiene Published: 11/6/23 Reference Number: 47664 Version: 8 Purpose: The purpose of this policy is to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination. Responsibility: All staff, patients...must follow the same requirements for hand hygiene. Policy: Hand hygiene includes either washing hands with soap and water or using a waterless alcohol-based antiseptic hand rub with 60-90 % alcohol content... ...Hand Hygiene: Patients: Patients should perform hand hygiene if able, prior to and after each dialysis treatment... ...Gloves must be provided to patients when performing procedures which risk exposure to blood or body fluids, such as...holding access sites post treatment... To help ensure the prevention of cross contamination to their family members or other patients, hand hygiene must be performed... 1. An observation of care was conducted on 1/23/24 at 12:17 PM with EI (Employee Identifier) # 3, Certified Clinical Hemodialysis Technician (CCHT), to discontinue dialysis of an AVF/AVG on PI # 12 at station 5. After holding pressure to both cannulation sites with a gloved hand, PI # 12 removed his/her glove and proceeded to exit the treatment floor without performing hand hygiene per facility policy. An interview was conducted on 1/25/24 at 8:52 AM with EI # 1, Clinical Manager who confirmed staff failed to ensure PI # 12 performed hand hygiene after removing gloves per facility policy. 42144 2. An observation of care was conducted on 1/23/24 at 10:30 AM with an unsampled patient at station 12 who was observed using her/his ungloved right hand to apply pressure to the left arm following discontinuation of dialysis. After holding pressure to the cannulation sites without a glove, the unsampled patient discarded the unclean gauze and applied new bandages to the cannulation sites and then proceeded to exit the treatment floor without performing hand hygiene per facility policy. An interview conducted on 1/25/24 at 8:40 AM with EI # 1 confirmed staff failed to ensure the unsampled patient at station 12 used a glove and performed hand hygiene after holding cannulation sites per facility policy.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 47295 Based on observations, review of facility policy and interviews, it was determined the facility failed to ensure staff wore required PPE (personal protective equipment) during care of patients who dialyzed with a CVC (Central Venous Catheter). This affected Patient Identifier (PI) # 2, one of two observations of CVC exit site care and one of two observations of initiation of dialysis with a CVC, and had the potential to affect all patients with CVCs who dialyzed at the facility. Findings include: Facility Policy: Personal Protective Equipment Published: 11/6/23 Reference Number: 47663 Version: 6 Purpose...to identify PPE and potential areas for use. Responsibility: Employees with potential exposure to hazardous chemicals, blood, or other potentially infectious material. ...Policy: ...Employees shall use PPE in accordance with the type of patient contact expected and anticipated exposure... PPE including a full-side shield, or mask and protective eyewear with full side shield...must be worn to protect employees from blood or other potentially infectious materials...when performing procedures in which spurting or spattering of blood might occur (...during initiation and termination of dialysis...). An observation of CVC exit site care was conducted on 1/23/24 at 12:30 PM at station 12, involving PI # 2 and EI # 4, Registered Nurse (RN). During CVC exit site care, PI # 2 and EI # 4 were wearing their masks below their noses during the procedure. EI # 4 then stepped away from station 12 and returned at 12:45 PM to initiate dialysis with a CVC. During the procedure, PI # 2’s mask remained below his/her nose. An interview was conducted on 1/25/24 at 9:15 AM with EI # 1, Clinical Manager, who confirmed the face mask must be worn above the nose during CVC exit site care and initiation of dialysis with a CVC and staff failed to follow the facility policy for PPE use and failed to ensure the patient’s mask was above his/her nose.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 49603 Based on observations, review of facility policy and interview, it was determined the facility failed to ensure the staff cleaned and disinfected equipment (stethoscope) after use on a patient. This did affect Patient Identifier (PI) # 11, 1 of 2 observations for Access of AVF/AVG (arteriovenous fistula/graft) for Initiation of Dialysis and had the potential to negatively affect all patients dialyzed at this facility. Findings Include: Facility Policy: Cleaning and Disinfection of the Dialysis Station Reference Number: 47806 Published: 09/05/2023 Version: 14 Purpose The purpose of this policy is to provide guidelines to prevent the spread of infectious disease in accordance with appropriate regulations, and to maintain a clean, safe, and aesthetically pleasant environment for patients, staff, and visitors. Responsibility All dialysis facility staff General Cleaning ... After use, any non-disposable equipment and supplies brought into the dialysis station (ex.{example} stethoscope), must be disinfected with 1:100 bleach or EPA (Environmental Protection Agency) registered disinfectant before being removed from the dialysis station. 1. An observation was conducted on 1/23/24 at 12:23 PM to observe Employee Identifier (EI) # 3, Certified Clinical Hemodialysis Technician (CCHT) perform a pre-assessment for initiation of dialysis with a stethoscope. After completion of all tasks, EI # 3 left the station with the stethoscope around his/her neck and failed to disinfect the stethoscope after use per facility policy. An interview was conducted on 1/25/24 at 8:52 AM with EI # 1, Clinical Manager who confirmed staff failed to clean and disinfect non-disposable equipment per facility policy.”

“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: 49603 Based on observations, review of facility policy and procedure, and interviews, it was determined the facility failed to ensure staff cleaned and disinfected the dialysis station after patient treatments and prior to setting up clean supplies on the hemodialysis machine for the next patient. This affected one of two observations of the cleaning and disinfection of the dialysis station and had the potential to affect all 59 patients dialyzing at this facility. Findings include: Facility Policy: Facility Policy: Cleaning and Disinfection of the Dialysis Station Published: 09/05/2023 Version: 14 Purpose The purpose of this policy is to provide guidelines to prevent the spread of infectious disease in accordance with appropriate regulations, and to maintain a clean, safe, and aesthetically pleasant environment for patients, staff, and visitors. Responsibility All dialysis facility staff ... Background The Centers for Medicare and Medicaid Services (CMS) has regulations that in order to prevent contamination, a dialysis station must be cleaned and disinfected between dialysis patients. The chair and dialysis equipment are used by multiple patients during a treatment day and it is critical that these items be thoroughly cleaned and disinfected between uses. Definition Dialysis Station: Area including the dialysis machine, chair/bed and other reusable equipment or supplies utilized during dialysis treatment... Equipment in the dialysis station may include... the following: Dialysis machine ... Chair/bed ... Individual television and remote. General Cleaning The dialysis station could become contaminated with blood and other body fluids during treatment. After use, any non-disposable equipment and supplies brought into the dialysis station must be disinfected ... Work Surface Cleaning and Disinfection without Visible Blood using Bleach Solutions All work surfaces shall be cleaned and disinfected with 1:100 bleach solution after completion of procedures. Make the surface glistening wet and let air dry unless otherwise specified by the manufacturer. ...Procedure Follow the steps below to disinfect the dialysis station after each dialysis treatment: Step: ...3. Use a cloth wetted with 1:100 bleach solution... to clean and disinfect the dialysis station (chair/bed, tables, machine, television... chaise wall behind chair... 4. Clean all surfaces... 1. An observation was conducted on 1/23/24 at 11:51 AM to observe Employee Identifier (EI) # 2, Patient Care Technician (PCT), perform cleaning and disinfection of station 1. EI # 2 failed to clean and disinfect a charging cord for the TV remote, underneath the chairside tabletops bilaterally, and the countertop behind the dialysis station. An interview was conducted on 1/25/24 at 8:52 AM with EI # 1, Clinical Manager, who confirmed staff failed to follow the facility policy for cleaning and disinfection of the dialysis station.”

“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: 47295 Based on observations, facility policy and procedure, and interview, it was determined the facility failed to ensure staff placed a clean under pad below the catheter limbs during discontinuation of dialysis with a CVC (Central Venous Catheter). This affected one of two observations for discontinuation of dialysis with a CVC and included Patient Identifier (PI) # 7 and had the potential to negatively affect all patients with CVCs who dialyzed at the facility. Findings include: Facility Policy: Termination of Treatment Using a Central Venous Catheter and Optiflux Single Use Ebeam Dialyzer Published: 2/7/22 Reference Number: 45640 Version: 7 Purpose...to provide direction to reinfuse blood in the extracorporeal system to the patient at completion of the hemodialysis treatment... Responsibility: FKC (Fresenius Kidney Care) Direct Patient Care Staff... ...Policy... ...Prior to Termination: Preparation... ...Step 5: Ensure that a clean under pad is below the catheter limbs to protect the work area and the clothing. 1. An observation was conducted on 1/23/24 at 4:45 PM at station 10 for PI # 7 by (Employee Identifier) EI # 4, Registered Nurse (RN), for discontinuation of dialysis with a CVC. EI # 4 failed to place an under pad below the catheter limbs prior to performing discontinuation of dialysis. An interview was conducted on 1/25/24 at 9:15 AM with EI # 1, Clinical Manager who confirmed staff failed to follow the facility policy for discontinuation of dialysis with a CVC.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 42144 Based on review of medical records (MR), facility policies and procedures, facility Blood Pressure and Weight Loss/Goal Algorithm, and interviews, it was determined the facility failed to ensure the staff: a) Followed facility Blood Pressure and Weight Loss/Goal Algorithm for the treatment of Blood Pressure and administered medications as ordered for Hypertension. b) Monitored and documented vital signs (VS) every (q) 30 minutes and safety checks per the facility policy but not to exceed 45 minutes. This affected four of seven MR’s reviewed including PI (Patient Identifier) # 1, PI # 4, PI # 2, PI # 6, and had the potential to negatively affect all patients who dialyzed at the facility. Findings include: Facility Policy: Patient Assessment and Monitoring Published: 5/1/23 Reference Number: 45284 Version: 4 Purpose: The purpose of this policy is to provide guidance... to direct care staff on assessment and monitoring patients before, during and after treatment... ...Pre-Treatment: ...Blood Pressure (BP) Record BP. Verify: Systolic Blood Pressure (SBP) greater than 180 and/or Diastolic Blood Pressure (DBP) greater than 100. ...Data Collection: ...The Registered Nurse (RN) will assess/re-assess any findings addressed pre or during treatment as needed. ...The RN will notify the patient’s physician/physician extender of any abnormal findings, if necessary, based on clinical judgment for additional instruction. ...During Treatment: ...Obtain BP and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes... ...Reposition electronic cuff or use a manual cuff for aberrant blood pressure readings. Report to the nurse: SBP greater than 180, DBP greater than 100 Facility Algorithm Date: 11/21/17 Blood Pressure and Weight Loss/Goal Algorithm Blood Pressure Notify MD (Medical Doctor)... Pre Systolic BP (Blood Pressure) is greater than 220 mm Hg (millimeters of mercury) Systolic BP is greater than 200 mm Hg after 1 (one) hour of dialysis Pre Diastolic BP is greater than 130 mm Hg Diastolic BP greater than 120 mm Hg after 1 hour of dialysis... Staff should address with MD...consistently high/low Blood Pressures... 1. PI # 1 was admitted to the facility on 9/4/23 with a diagnosis of End Stage Renal Disease (ESRD). Review of the Order Summary Report dated 12/5/23 revealed an order for Clonidine HCL (Hydrochloride) 0.1 mg (milligram) oral PRN (as needed) HTN (Hypertension). Review of the Treatment Sheet (TS) dated 1/4/24 revealed vital signs including blood pressure were assessed at 5:35 AM and not again until 6:28 AM which exceeded 45 minutes per policy. Further review of the TS dated 1/4/24 revealed dialysis started at 5:21 AM and at 8:56 AM, the blood pressure was 209/72 and at 9:19 AM 209/92. There was no documentation Clonidine HCL was administered and no documentation the physician was notified. Review of the TS dated 1/6/24 revealed dialysis started at 5:36 AM and at 9:43 AM, the blood pressure was 209/70. Further review of the TS dated 1/6/24 revealed a post dialysis blood pressure of 212/72 sitting and 211/96 standing. There was no documentation Clonidine HCL was administered and no documentation the physician was notified. An interview conducted on 1/25/24 at 8:40 AM with EI (Employee Identifier) # 1, Clinical Manager confirmed staff failed to administer Clonidine per physician’s orders, failed to notify the physician of the systolic blood pressure greater than 200 and failed to assess VS every 30 minutes not to exceed 45 minutes per the facility policy. 47295 2. PI # 4 was admitted to the facility on 8/2/23 with a diagnosis of ESRD. Review of the TS dated 1/19/23 revealed VS assessed at 10:34 AM and VS not assessed again until 11:33 AM which was greater than 45 minutes per policy. An interview conducted on 1/25/24 at 8:40 AM with EI # 1 confirmed staff failed to assess VS every 30 minutes not to exceed 45 minutes per the facility policy. 3. PI # 2 was admitted to the facility on 9/4/23 with a diagnosis of ESRD. Review of the TS dated 1/6/24 revealed VS assessed at 1:33 PM and VS not assessed again until 2:36 PM which was 1 hour and 3 minutes later. An interview conducted on 1/25/24 at 8:46 AM with EI # 1 confirmed staff failed to asses VS every 30 minutes not to exceed 45 minutes per policy. 4. PI # 6 was admitted to the facility on 11/5/21 with a diagnosis of ESRD. Review of the Orders Summary Report dated 12/8/23 revealed orders for Clonidine HCL 0.1 mg oral PRN HTN. Review of the TS dated 1/17/24 revealed VS assessed at 12:58 PM and VS not assessed again until 3:04 PM which was 2 hours and 6 minutes later. Review of the TS dated 1/22/24 revealed dialysis started at 9:39 AM. At 10:46 AM the BP was 207/110. There was no documentation Clonidine HCL was administered and no documentation the physician was notified. Further review of the TS dated 1/22/24 revealed documentation the RN was notified of the elevated BPs at 9:39 AM and 11:03 AM. There was no documentation the RN assessed the patient after being made aware of the elevated BPs. An interview conducted on 1/25/24 at 8:49 AM with EI # 1 confirmed staff failed to administer Clonidine per physician’s orders, failed to notify the physician of an SBP greater than 200, failed to assess VS every 30 minutes not to exceed 45 minutes per the facility policy, and the RN failed to re-assess the patient after being made aware of the elevated BPs.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 39098 Based on review of Medical Records (MR), facility policy, and staff interviews, it was determined the facility failed to ensure staff followed the physician’s orders for Blood Flow Rate (BFR) and Dialysate Flow Rate (DFR). This affected six of seven MRs reviewed and had the potential to affect all 59 patients who dialyzed at this facility, and did affect Patient Identifier (PI) # 5, PI # 3, PI # 7, PI # 1, PI #2, and, PI # 6. Findings include: Facility Policy: Patient Assessment and Monitoring Published: 05/01/2023 Reference Number: 45284 Version: 4 Purpose: The purpose of this policy is to provide guidance... to direct care staff on assessment and monitoring patients before, during and after treatment. ...During Treatment ...3. Machine Parameters and Extracorporeal Circuit Check machine settings and measurements: Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. Check dialysate flow rate setting is correct, and the prescribed flow is being delivered... ...Document machine parameters and safety checks every 30 minutes or more often as needed but not to exceed 45 minutes... 1. PI # 5 was admitted to the facility on 1/2/24 with a diagnoses of End Stage Renal Disease (ESRD). Review of the Orders Summary Report dated 1/2/24 revealed an ordered BFR 450, and DFR 800. Review of the Treatment Sheet (TS) dated 1/11/24 revealed the BFR was 235 from 8:15 AM to 9:34 AM. There was no documentation why the BFR was not 450 as ordered. Review of the TS dated 1/20/24 revealed the BFR was 350 from 1:30 PM to 4:31 PM, the entire treatment. There was no documentation why the BFR was not 450 as ordered. An interview was conducted on 1/25/24 at 8:37 AM with Employee Identifier (EI) # 1, Clinical Manager, who confirmed staff failed to maintain the physician ordered BFR. 49603 2. PI # 3 was admitted to the facility on 9/26/22 with a diagnosis of ESRD. Review of the Orders Summary Report dated 12/08/23 revealed an ordered BFR 450. Review of the TS dated 1/5/24 revealed the BFR at 400 from 11:27 AM until 12:57 PM, and not at 450 as ordered. There was no documentation why the BFR was not 450 as ordered. Review of TS dated 1/22/24 revealed the BFR at 350 for the entire treatment, from 10:34 AM until 1:32 PM, and not at 450 as ordered. There was no reason documented why the BFR was 350 and not at 450 as ordered. An interview was conducted on 1/5/24 at 8:52 AM with EI # 1, who confirmed the staff failed to maintain the physician ordered BFR. 42144 3. PI # 7 was admitted to the facility on 10/29/22 with a diagnoses of ESRD. Review of the Orders Summary Report dated 1/11/24 revealed an ordered DFR of 800. Review of the TS dated 1/13/24 revealed the DFR was 500 the entire treatment from 12:59 PM to 4:16 PM. There was no documentation why the DFR was not 800 as ordered. An interview conducted on 1/25/24 at 8:40 AM with EI # 1 confirmed there was no documentation why the DFR was not run at the ordered rate of 800. 4. PI # 1 was admitted to the facility on 9/4/23 with a diagnosis of ESRD. Review of the Orders Summary Report dated 12/16/23 revealed an ordered BFR of 350. Review of the TS dated 1/16/24 revealed the BFR was 285 from 12:12 PM to 12:33 PM when it was changed to 300 and remained at 300 until the treatment ended at 3:13 PM. There was no documentation why the BFR was not at the ordered rate 350. An interview conducted on 1/25/24 at 8:40 AM with EI # 1 confirmed there was no documentation why the BFR was not run at the ordered rate of 350. 47295 5. PI # 2 was admitted to the facility on 9/4/23 with a diagnosis of ESRD. Review of the Orders Summary Report dated 12/19/23 revealed an ordered BFR 400 and DFR 800. Review of the TS dated 1/6/24 revealed the BFR/DFR rates were documented at 1:33 PM and not documented again until 2:36 PM (1 hour and 3 minutes later). The staff failed to document the BFR and DFR every 30-45 minutes per facility policy. Review of the TS dated 1/11/24 revealed the BFR/DFR rates were documented at 12:00 PM and not documented again until 1:29 PM (1 hour and 29 minutes later). The staff failed to document the BFR and DFR every 30-45 minutes per facility policy. Review of the TS dated 1/18/24 revealed the DFR rate was decreased from the ordered rate of 800 to 700 at 12:03 PM to 1:02 PM (59 minutes later). There was no documentation why the DFR was not at the ordered rate. An interview was conducted on 1/25/24 at 8:46 AM with EI # 1, who confirmed staff failed to maintain the physician ordered DFR and also failed to follow the facility policy for documentation of BFR/DFR not to exceed 45 minutes. 6. PI # 6 was admitted to the facility on 11/5/21 with a diagnosis of ESRD. Review of the Orders Summary Report dated 12/18/23 revealed an ordered BFR 400 and DFR 800. Review of the TS dated 1/12/24 revealed the BFR/DFR rates were documented at 10:23 AM and not documented again until 11:19 AM (56 minutes later). The staff failed to document the BFR and DFR every 30-45 minutes per facility policy. Review of the TS dated 1/15/24 revealed the BFR rate was 350 from 11:06 AM to 11:30 AM (24 minutes). There was no documentation why the BFR was not at the ordered rate of 400. Review of the TS dated 1/17/24 revealed BFR/DFR rate not documented from 12:58 PM to 3:04 PM (2 hours and 6 minutes). The staff failed to document the BFR and DFR every 30-45 minutes per facility policy. An interview was conducted on 1/25/24 at 8:49 AM with EI # 1, who confirmed staff failed to maintain the physician ordered BFR and also failed to follow the facility policy for documentation of BFR/DFR not to exceed 45 minutes.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 49603 Based on observation, review of facility policy and procedure and interview, it was determined the facility failed to ensure staff performed AVF/AVG (arteriovenous fistula/graft) site preparation per facility procedure in two of two observations conducted for AVF/AVG access and initiation of dialysis, including PI (Patient Identifier) # 10 and # 11. This had the potential to negatively affect all patients dialyzing at this facility with an AVF/AVG access. Findings include: Facility Policy and Procedure: Access Assessment and Cannulation Published: 7/5/22 Reference Number: 45178 Version: 3 ...Background... The access must be prepared properly for needle placement to prevent bacteria from entering the bloodstream through the skin... Policy: Evaluation and preparation of the access will be performed routinely prior to cannulation at each dialysis session. Skin Disinfection: Step 1: Disinfect cannulation site as follows using any of the disinfectants below: ... 70 % (percent) isopropyl alcohol pad: Using gentle friction, clean the access site... for 30 seconds and allow to dry before cannulating... Step 2: Perform skin antisepsis on one site at a time, allow to dry and then cannulate. 1. An observation of care was conducted on 1/23/24 at 10:49 AM with EI (Employee Identifier) # 2, Patient Care Technician (PCT), at station 3 for access of AVF/AVG for initiation of dialysis on PI # 10. Using an alcohol pad, EI # 2 performed antisepsis to one site of the AVF/AVG for approximately fifteen seconds, retrieved the needle and cannulated the site. EI # 2 then utilized another alcohol pad and performed antisepsis for approximately five seconds to the second site, retrieved the needle and cannulated the site. EI #2 failed to clean each site for 30 seconds and allow the alcohol to dry, prior to cannulation, per facility policy. An interview was conducted on 1/25/24 at 8:52 AM with EI # 1, Clinical Manager, who confirmed EI # 2 failed to perform antisepsis of the cannulation sites per facility policy and procedure. 2. A second observation of care was conducted on 1/23/24 at 12:23 PM with EI #3, Certified Clinical Hemodialysis Technician (CCHT), at station 1 for access of AVF/AVG for initiation of dialysis on PI # 11. Using an alcohol pad, EI # 3 performed antisepsis to one site of the AVF/AVG for approximately fifteen seconds, retrieved the needle and cannulated the site. EI # 3 then utilized another alcohol pad and performed antisepsis for approximately fifteen seconds to the second site, retrieved the needle and cannulated the site. EI #2 failed to clean each site for 30 seconds and allow the alcohol to dry, prior to cannulation, per facility policy. An interview was conducted on 1/25/24 at 8:52 AM with EI # 1, who confirmed EI # 3 failed to perform antisepsis of the cannulation sites per facility policy.”