Davita South Sacramento Dialysis Center

“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: 45718 Based on observation, interview and record review, the facility failed to ensure the facility staff followed hand hygiene procedures (act of cleaning your hands can prevent the spread of germs), while caring for dialysis patients. This failure had the potential to increase the patient’s risk for infections and cross contamination. Findings: During an observation on 11/22/23 at 8:15 a.m., at the treatment area in Pod 1, the Patient Care Technician (PCT 2) was observed removing gloves after touching the hemodialysis machine (Hemodialysis, a procedure where a dialysis machine and a special filter called an artificial kidney, or a dialyzer, are used to clean the blood) and proceeded to type on the clean chair side computer without doing hand hygiene after removing her gloves. During an observation on 11/22/23 starting at 8:25 a.m., at the treatment area in Pod 3, the Licensed Nurse (LN 1) was observed terminating the treatment for a patient. The LN 1 was observed removing her gloves and proceeded to type on the clean chairside computer without doing hand hygiene. The LN 1 then wore a new pair of gloves and checked the patient’s standing blood pressure, LN 2 then removed her gloves and typed on the chairside computer without doing hand hygiene. During an observation on 11/22/23 starting at 8:34 a.m., at the treatment area, the LN 2 was observed starting a patient when a machine across the room started to alarm. The LN 2 went to press the machine alarm without changing gloves. The LN 2 then removed his gloves and wore a new pair of gloves and went back to his patient without doing hand hygiene in between glove change. During an observation on 11/22/23 starting at 8:38 a.m., at the treatment area in Pod 5, PCT 2 was observed removing needles from a patient. PCT 2 removed her gloves and typed on the clean chairside computer without doing hand hygiene. She then wore a new pair of gloves, changed the patient’s dressing that was soaked with blood, removed her gloves, and then went to get a blue pad in the clean area supplies without doing hand hygiene in between tasks. During an observation on 11/22/23 starting at 9:34 a.m., the PCT 2 was observed removing her gloves and taking supplies from the clean area supplies without doing hand hygiene in between. She then wore a new pair of gloves and cannulated and hooked the patient to the hemodialysis machine. The PCT 2 then took the blanket from the patient’s wheelchair and placed the blanket on the patient with the same gloves. She then removed her gloves and proceeded to type on the clean chair side computer without doing hand hygiene in between tasks and glove change. During an interview on 11/22/23 at 9:40 a.m., the PCT 2 acknowledged that she missed doing hand hygiene in between glove change earlier. She stated, she needs to do hand hygiene after taking off her gloves and in between changing gloves. She further stated, hand hygiene should be done to prevent the spread of infection. During an interview on 11/22/23 at 8:45 a.m., the LN 1 stated, hand hygiene should be done any time when switching gloves, it should also be done in between tasks and in between glove change. During an interview on 11/22/23 at 9:15 a.m., with the Facility Administrator (FA), the FA stated, he expects the staff to wash their hands or perform hand hygiene, in between tasks and in between glove changes because of the risk for cross contamination between patients. He further stated, the staff needs to do hand hygiene properly every time they take something from the clean supplies area to avoid cross contamination. A review of the facility policy titled, “INFECTION CONTROL FOR DIALYSIS FACILITIES”, revised April 2023, indicated, “ ...HAND HYGIENE ...1. All teammates ...will perform hand hygiene ...b. prior to gloving and immediately after removal of gloves ...d. after patient and dialysis delivery system contact ...g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse ...””

“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: 44798 Based on observation, interview, and record review the facility to ensure one staff wore a surgical mask properly when on the treatment floor. This failure had the potential to result in the exposure of staff and patient to infection and/or disease. Findings: During an observation on 11/22/23 at 8:20 a.m., Patient Care Technician (PCT) 1 was observed on the treatment floor wearing a gown and a surgical mask while providing patient care. The surgical mask was observed to be below the nose. During an interview on 11/22/23 at 8:25 a.m. with PCT 1, PCT 1 stated he did not get the flu shot and it was their policy to wear the mask. PCT 1 confirm not wearing a surgical mask properly and stated it should be worn over the nose. PCT 1 further stated the risk of not wearing it correctly was patient safety. A review of the facility’s document titled “Flu Vaccine: Status of TM [teammate] working,” undated, indicated PCT 1 was not vaccinated for the flu prior to 11/22/23. During an interview on 11/22/23 at 8:42 a.m. with Licensed Nurse (LN) 1, LN 1 stated the purpose of wearing a surgical mask is to prevent any transfer of respiratory droplets to the patient, patient safety. LN 1 further stated if staff did not get the flu shot, they are required to wear the surgical mask every time. LN 1 also mentioned the surgical mask should be over the nose and not below the nose. During an interview on 11/22/23 at 9:01 a.m. with the Facility Administrator (FA), the FA stated if a staff did not have a flu shot, they would have to wear a surgical mask all day long until flu season was over. The FA further stated the proper way of wearing a surgical mask is over their nose. The FA mentioned the risk of not wearing a surgical mask properly is patient safety as they have immunocompromised patients. A review of the facility’s policy titled, “CLINICAL HEALTHCARE PERSONNEL/TEAMMATE INFLUENZA VACCINATION,” Revision dated October 2020, the policy indicated, “ ...This policy is in effect for the entire influenza reporting season; October 1st-March 31st each year ...Beginning November 1st to March 31st, all HCP [health care provider] are required to complete one of the following ... Have received an annual influenza vaccination; or ...Wear a procedure mask covering their nose and mouth at all times while in patient care areas ...””

“MR-PROTECT PT RECORDS FM LOSS/CONFIDENTIAL CFR(s): 494.170(a) The dialysis facility must- (1)Safeguard patient records against loss, destruction, or unauthorized use; and (2) Keep confidential all information contained in the patient’s record, except when release is authorized pursuant to one of the following: (i) The transfer of the patient to another facility. (ii) Certain exceptions provided for in the law. (iii) Provisions allowed under third party payment contracts. (iv) Approval by the patient. (v) Inspection by authorized agents of the Secretary, as required for the administration of the dialysis program. This Standard is not met as evidenced by: 45718 Based on observation, interview and record review, the facility failed to protect confidential patient health information when 5 computer screens were left open and unattended during Hemodialysis treatment (Hemodialysis, a procedure where a dialysis machine and a special filter called an artificial kidney, or a dialyzer, are used to clean the blood). This failure had the potential to result in patient information being accessed by unauthorized individuals, that could affect the patient’s overall health and safety. Findings: During an observation on 11/22/23 at 9:50 a.m., at the treatment area, computer screens in terminals 7, 15,17, 19, and 21, were open and left unattended by staff while patients were undergoing hemodialysis. Information such as patient name, treatment details and monitoring were left visible. During an interview on 11/22/23 at 10:02 a.m., the Patient Care Technician (PCT 3) confirmed the terminal 7 computer screen was left opened and unattended with patient details of going treatment visible. She stated, the computer usually logs you off automatically, but she does not know why the computer was left open. During an interview on 11/22/23 at 10:20 a.m., the PCT 4 confirmed the terminal 15 and terminal 19 computer screens were left opened and unattended with patient details of going treatment visible. She stated the staff was supposed to log out of the computer. During a telephone interview on 11/22/23 at 10:27 a.m., with the Clinical Specialist (CS), the CS stated, if the staff are right there then it’s okay to keep the computer screen open, once the staff walks away, they should log off. If they are not with the patient, the computer screens should not be kept opened. The CS stated, she expects for the staff to log off the computer once they walk away. A review of the facility policy titled, “ADMINISTRATIVE, TECHNICAL AND PHYSICAL SAFEGUARDS FOR PROTECTED HEALTH INFORMATION”, revised, June 2022, indicated, “ ...1. All Teammates ...are responsible for ensuring that physical access control and other administrative, technical, and physical safeguards are implemented to limit physical access to the facilities and to protect PHI [Protected Health Information] against unauthorized access ... d. Computers/Electronic Medical Equipment: ii. Teammates are required to log off terminals or use the “lock workstation” function prior to leaving the work area ...””