032549 Safford Dialysis (Fmc)

“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: 37489 Based on document review, observation, and interview, it was determined that the facility failed to ensure (2) of (2) dialysis stations were cleaned and disinfected prior to setting up the dialysis machine with new supplies for the next patient shift which poses a potential risk for infection through cross contamination and contact transmission of potentially infectious bloodborne organisms between patients at the station. Findings include: The facility policy titled “Cleaning and Disinfecting the Dialysis Station” requires: “...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...a dialysis station must be cleaned and disinfected between dialysis patients...Dialysis station...Area including the dialysis machine, chair/bed and other reusable equipment or supplies utilized during dialysis treatment...The dialysis station could become contaminated with blood and other body fluids during treatment...Follow the steps below to disinfect the dialysis station after each dialysis treatment...Use a cloth wetted with...disinfectant to clean and disinfect the dialysis station (chair/bed, tables, machine...)...Place the chair in Trendelenburg...so all surfaces of the chair are accessible. Clean all surfaces...Give special attention to the cleaning control panel on the dialysis machine and other surfaces that are frequently touched and potentially contaminated with patient’s blood and/or body fluids...Pick up all trash or visible medical debris from around the patient chair....” Observation on 10/23/2024 at 0955 revealed Employee #19 breaking down/setting up station #13 after dismissing the first shift patient. Employee #19 cleaned and disinfected the dialysis machine; however, s/he did not clean and disinfect the dialysis chair at station #13 prior to stringing/priming a new extracorporeal circuit, installing a new bibag (bicarbonate), and initiating machine testing. Employee #19 set up new machine supplies for the next patient before discarding used gauze, tape, and chux and removing a dirty hemostat from the chairside table and cleaning and disinfecting the chair which the employee did while the dialysis machine was running though the testing procedure for the next patient. Observation on 10/23/2024 at 0955 revealed Employee #11 breaking down/setting up station #11 after dismissing the first shift patient. Employee #11 cleaned and disinfected the dialysis machine; however, s/he did not clean and disinfect the dialysis chair at the station prior to stringing a new extracorporeal circuit. There were dirty chux and used gauze from the prior patient on the chairside table and the chair had not been cleaned and disinfected as Employee #11 was stringing a new circuit and installing a new dialyzer for the second shift patient. Employees #3 and 27 confirmed in separate interviews on 10/23/2024 that Employees #11 and 19 did not clean and disinfect the entire dialysis station prior to setting up new, clean supplies for the next shift of patients as required by policy.”