Davita Antelope Dialysis Center

“IC-CDC MMWR 2001 CFR(s): 494.30(a) The facility must demonstrate that it follows standard infection control precautions by implementing- (1)(i) The recommendations (with the exception of screening for hepatitis C), found in “Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients,” developed by the Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, volume 50, number RR05, April 27, 2001, pages 18 to 28. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html. The recommendation found under section header “HBV-Infected Patients”, found on pages 27 and 28 of RR05 (“Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients”), concerning isolation rooms, must be complied with by February 9, 2009. This Standard is not met as evidenced by: 45718 Based on observation, interview, and record review, the facility failed to follow standards of infection control precautions when used needles were found on top of two Hemodialysis (Artificial means of kidney function that cleanses the blood by passing it through a filter called a DIALYZER) machine blood pumps. This failure had the potential to transmit infectious diseases. Findings: During an observation on 1/18/24 at 10:18 a.m., a used needle was found on the top of Patient 1’s hemodialysis machine blood pump. During a concurrent observation and interview on 1/18/24 at 10:32 a.m., the Licensed Nurse (LN 1), verified there was a used needle on the top of Patient 1’s hemodialysis machine blood pump while he was having hemodialysis. She stated, “they [staff] forgot to throw it away ...it should not be there.” LN 1 proceeded with throwing the needle in the sharps container bin. During an observation on 1/18/24 at 10:40 a.m., a used needle was found on the top of Patient 2’s hemodialysis machine blood pump. During a concurrent observation and interview on 1/18/24 at 10:42 a.m., the Patient Care Technician (PCT 1), verified there was a used needle on the top of Patient 2’s hemodialysis machine blood pump. She stated, it’s supposed to be in the sharps container. She further stated, “it is important to throw it away so that we don’t accidentally get pricked, it’s for patient’s safety”. PCT 1 proceeded with throwing the needle in the sharps container bin. During an interview on 1/18/24 at 12:43 p.m., the Facility Administrator (FA) stated, she expected the staff to dispose of used needles in the sharps container immediately and not leave them on top of the machine. A review of Centers for Disease Control and Prevention (CDC) document titled, “GUIDE TO INFECTION PREVENTION FOR OUTPATIENT SETTINGS: MINIMUM EXPECTATIONS FOR SAFE CARE”, version 2.3 September 2016, indicated, “ ...Key recommendations for safe injection practices in outpatient settings ...8. Dispose of used sharps at the point of use in a sharps container that is closable, puncture-resistant, and leak-proof ...” https://www.cdc.gov/infectioncontrol/pdf/outpatient/guide.pdf”

“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 implement standards of infection control precautions when: 1.Two Patient Care Technicians (PCT) did not perform hand hygiene (includes either washing with soap and water or using an approved alcohol-based hand gel) in between glove change on multiple occasions while caring for patients with on-going Hemodialysis (HD, Artificial means of kidney function that cleanses the blood by passing it through a filter called a DIALYZER), and 2. A PCT used inappropriately covered hand when touching a hemodialysis machine in use. These failures had the potential to increase the patients’ risk for infections and cross contamination. Findings: 1.During an observation on 1/18/24 at 10:30 a.m., in the treatment area, PCT 1 was observed starting a patient on HD. PCT 1 placed the blood pressure cuff on the patient. PCT 1 then proceeded to type on the clean chair side computer while still wearing the same used gloves. PCT 1 removed her gloves and did not perform hand hygiene thereafter. During further observation on 1/18/24 at 10:32 a.m., PCT 1 was observed wearing a new pair of gloves and pressed the HD machine. She then removed her gloves, went to another patient and wore new gloves without performing hand hygiene in between glove change. During an observation on 1/18/24 at 11:15 a.m., PCT 2 was observed removing his used gloves and grabbing clean supplies in the clean area. PCT 2 then proceeded to a patient and wore new pair of gloves without performing hand hygiene in between tasks and glove change. During an observation on 1/18/24 at 11:53 a.m., PCT 2 was observed removing used dialysis lines from HD machine. PCT 2 proceeded to throw the lines in the garbage bin, removed gloves, went to type on the clean chairside computer. PCT 2 did not perform hand hygiene in between tasks and glove change. During an observation on 1/18/24 at 12:03 p.m., PCT 2 removed his gloves after cleaning the HD machine and proceeded to prepare supplies in the clean supply area without performing hand hygiene. During an interview on 1/18/24 at 12:43 p.m., the Facility Administrator (FA) stated, the staff needed to change gloves every time they go to a new machine and hand sanitize in between changing gloves. 2. During an observation on 1/18/24 at 11:55 a.m., PCT 2 was observed pressing the machine alarm where a patient was dialyzing with only the index finger covered with gloves. PCT 2 then proceeded to remove the gloves on his index finger and did not perform hand hygiene thereafter. During an interview on 1/18/24 at 12:43 p.m., the Facility Administrator (FA) stated, the staff needed to wear gloves properly when they are touching the machine. The FA stated, the gloves should be on their hand and not in their index finger only. 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 ...””