Davita Crossroads 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: 18750 Based on observation, interview and policy review, the facility failed to ensure staff changed gloves and performed hand hygiene between tasks with two of 12 sampled patients (Patient (P)11 and P12). This deficient practice had the potential to allow cross contamination between patients and equipment which could cause infections. Findings include: 1. Observation on 12/13/23 at 11:50 AM, revealed Patient Care Technician (PCT)1 was discontinuing the treatment for P11. PCT1 pulled off the blood lines from the machine and took them to the trash. PCT1 then went over to the bleach bucket and reached in with the same gloves and pulled out gauze that had been soaked in the bleach. Then without changing gloves, PCT1 the walked then over to the machine and set them on top of the machine. PCT1 walked P11 to get weighed while carrying P11’s bag and got the weight. PCT1 then walked P11 out of the treatment room area. PCT1 then returned and began to wipe down the machine. After wiping the machine and the chair, PCT1 wiped down the oxygen concentrator and took it back to where the other concentrators were stored. PCT1 then discarded the gloves and washed hands. During an interview on 12/13/23 at 12:15 PM, PCT1 was asked about the wearing of gloves and when they should have been changed. PCT1 said that the gloves should have been changed when the blood lines were removed from the machine. PCT1 said that the same gloves should not have been worn while getting the bleach gauze or when walking the patient out. During an interview on 12/13/23 at 12:35 PM, the Manager of Clinical Services was asked about the observation. The Manager of Clinical Services stated, “The gloved and hand hygiene should have been changed when a task ended.” 2. During an observation on 12/14/23 at 9:33 AM, PCT2 was observed at Station 3 to disconnect P12 from the treatment. While putting tape on the side table, the alarm sounded at Station 1. PCT2 walked over to Station 1 and fixed the alarm on machine and then walked back to Station 3 and continued to work with P12 without discarding gloves and performing hand hygiene. During an interview on 12/13/23 at 9:49 AM, PCT2 was asked about wearing the same gloves from Station 3 to Station 1 without changing them. PCT2 stated, “I should have changed gloves and performed hand hygiene before going over to Station 1. Then discarded those gloved and perform hand hygiene when I came back.” During an interview on 12/13/23 at 12:15 PM, the Manager of Clinical Services stated the gloves and hand hygiene should have been done with a new task. During an interview on 12/15/23 at 10:30 AM, The Administrator and Nurse Manger were asked about the observations of the lack of glove change and hand hygiene. The Administrator and Nurse Manager stated the staff should have performed hand hygiene and put on new gloves with the change of task. Review of the facility policy titled, “Infection Control for Dialysis Facilities,” ith a revised date of April 2023, revealed, “Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. . . HAND HYGEINE l. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, e. after interacting with wall boxes (i.e., plugging/unplugging acid/bicarb lines form dialysis machine, changing acid types, when exchanging a dialysis machine) f. between patients even if the contact is casual, 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: 18750 Based on observation, interview, and policy review, the facility failed to follow facility policy regarding the wearing of Personal Protective Equipment (PPE) when working with one of one sampled patient (Patient (P)5) in isolation. Findings include: During an observation on 12/13/23 at 12:05 PM, Licensed Vocational Nurse (LVN)1 was observed to be with P1 who was in isolation at Station 20. LVN1 was wearing a gown and was replacing the blood pressure cuff on P1’s arm. The patient’s arm was up against the gown of LVN1. LVN1 then walked away and disposed of the gloves and performed hand hygiene but continued to wear the same gown. LVN1 then proceeded over to Station 23 and began setting it up for the next patient. During an interview on 12/13/23 at 12:06 PM, LVN1 was asked about wearing the same gown with P1 and then going over to station 23 to set up without changing the gown. LVN1 stated the gown should have been changed after contact with P1. Review of P1’s medical record revealed an admission date of 04/09/22 with end stage renal disease and Canida auris (a type of fungus that grows as yeast) of the skin. P1 was in contact isolation. During an interview on 12/13/23 at 12:35 PM, the Manager of Clinical Services was asked about the observation in which the staff member did not change the gown after working with P1. The Manager of clinical services stated, “The gown should have been change before the staff went on to do anything else.” During an interview on 12/15/23 at 10:30 AM, the Administrator and Nurse Manager were asked what the expectation was when staff worked with patients in contact isolation. The Administrator and Nurse Manger both agreed that the expectation was that the gown would be changed after each encounter with the patient. Review of the facility’s policy titled, “Candida Auris Management,” with a date of October 2023, revealed, “Purpose: To provide guidance to prevent transmission of Candida auris (C. auris) in the outpatient dialysis setting. Policy: Transmission Based Precautions. . .Gown- Separate long-sleeved garment that is removed and discarded after caring for the patient. . .””

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 18750 Based on observation, interview, facility policy review, and review of the facility’s “Safety Data Sheet,” the facility failed to ensure the oxygen canisters were stored appropriately by leaving two canisters unsecured and empty mixed with the full canisters. This deficient practice had the potential to allow the unsecured canister to fall that could release the pressure in the canister and propel through anything in the path, and in an emergency grabbing a canister that is empty in an emergency. Findings include: Review of safety data sheets titled, “Oxygen Compressed,” provided by the facility with a revision date of 01/27/21, revealed, “. . .Section 7: Handling and storage. . . 7.2 Conditions for safe storage, including an incompatibilities. . . Always secure containers upright to keep them from falling or being knocked over. . . Store full and empty containers separately. . .” During an observation on 12/13/23 at 10:33 AM, in an area on the treatment floor were 11 oxygen canisters. One canister had a full tag around the top, standing and not secured in a cart. Another canister was lying on the floor with an empty tag around the top. Six canisters had a tape on the top indicating they were full. Three canisters did not have a tag on the top indicating whether they were full or empty. The canisters were behind a broom leaning against the shelf. During an interview on 12/13/23 at 10:44 AM, the Manager of Clinical Services was asked if there was anything wrong with the oxygen canisters. The Manager of Clinical Services stated, “well it is a bit of a mess, and there are empty canisters mixed with full. Oh, there are two canisters that should be in a cart they are unsecure.” The Manager of Clinical Services was asked what could happen. The Manager of Clinical Services stated, “Well and empty canister could be grabbed if there was an emergency, and someone needed oxygen. Also, the unsecure oxygen canisters could fall over and blow up.” During an interview on 12/15/23 at 10:30 AM, the Nurse Manager and Facility Administrator were asked what their expectations were regarding the oxygen. They both agreed oxygen should always be secured in a cart or crate and empties should be stored separately from full canisters. Review of the facility’s policy titled, “Emergency Equipment Checks,” with a revision date of April 2022 revealed, “Purpose: To verify that emergency equipment is maintained in a ready-to-use condition. Policy. . . 7. The oxygen tank(s) will be checked for an adequate amount of oxygen (500 psi [per square inch] or more) and stored in compliance with local and/or state regulations. . .””