Davita Pikes Peak Dialysis Center

“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: 45020 Based on observations, interviews, and document reviews, the facility failed to ensure patient care staff cleaned and disinfected the patient treatment station chair per facility policy in one of two observations of dialysis station cleaning. Specifically, staff did not allow the chair to fully dry. Findings include: Facility policy: The Infection Control for Dialysis Facilities policy read, the purpose of this policy is to minimize the spread of infections or blood borne pathogens in the dialysis facility environment. At the end of each treatment, the dialysis station will be cleaned and disinfected. Surfaces to disinfect include but are not necessarily limited to all surfaces in contact with the patient or their belongings (e.g., dialysis chair). Use an appropriate disinfectant such as 1:100 (one to one hundred) bleach solution for routine disinfection of environmental surfaces. Disinfection should be completed by using a wiping motion with friction. Sufficient disinfectant should be applied so that surfaces are visibly wet. Surfaces should be allowed to air dry in order to provide sufficient disinfectant contact time. Reference: According to the manufacturer’s instructions for use for Pure Bright germicidal ultra bleach, for sanitizing non-porous surfaces, prepare a solution of this product, wash surface, let stand 5 minutes to air dry. 1. The facility failed to ensure patient care staff cleaned and disinfected contaminated surfaces at the dialysis station, specifically the dialysis chair, between patient treatments according to facility policy and the manufacturer’s instructions. a. On 11/13/23 at 4:17 p.m., registered nurse (RN) #1 was observed as she disinfected the dialysis chair in station #13. RN #1 wiped all visible surfaces of the chair with a bleach solution, placed the chair into a fully reclined position to wipe the crevices, but closed the side arms while the chair remained visibly wet. b. On 11/15/23 at 1:48 p.m., an interview was conducted with RN #2. RN #2 stated dialysis chairs were to be fully reclined with all surfaces cleaned with a bleach solution. RN #2 further stated the chair’s arms were to be left open until dry because the dialysis chair was not considered clean until it was dry. RN #2 stated she was unsure of the risk if dialysis chairs were closed while wet. c. On 11/16/23 at 9:39 a.m., an interview was conducted with patient care technician (PCT) #3. PCT #3 stated dialysis chairs were to be disinfected between every patient to prevent cross-contamination. PCT #3 stated all surfaces of the chair were to be disinfected with a bleach solution, the chair was to be fully reclined and the side arms were to be opened. She further stated the chair’s arms were to be opened and every surface was to be cleaned and left open and reclined until dry. d. On 11/16/23 at 9:56 a.m., an interview was conducted with RN #5. RN #5 stated dialysis chairs were disinfected after every patient because the chairs were considered dirty after patient use. RN #5 stated all surfaces of the dialysis chair were expected to be cleaned and the dialysis chair was to be left reclined with the side arms open until dry. RN #5 stated if dialysis chairs were not left open to air dry there was an infection risk to the patients. This was in contrast with the observation of RN #1 which revealed the dialysis chair was not left open until fully dry.”

“IC-CATHETERS:GENERAL CFR(s): 494.30(c)(2) (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. 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 as 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 This Standard is not met as evidenced by: 45020 Based on observations, interviews, and document review, the facility failed to ensure patient care staff cleaned the central venous catheter (CVC) (a device inserted through the skin for direct access to a large vein in the patient for dialysis treatment) access (the CVC exit site) according to facility policy in two of three observations of staff accessing CVCs. Findings include: Facility policies: The CVC with Clearguard Hemodialysis (HD) (cleaning the blood using a machine and a filter) Antimicrobial End Caps Procedure read, perform a 15-second hub scrub of the CVC during the process of connecting or disconnecting from the bloodlines, or if the patient is disconnected during treatment for any reason. Perform hand hygiene per procedure. Remove old dressing and discard. Verify that both arterial and venous catheter limbs (tubing) are clamped. Remove gloves and discard. Perform hand hygiene per procedure and re-glove. Holding catheter and using aseptic technique, clean exit site with 2% Chlorhexidine Gluconate/70% Isopropyl Alcohol for a minimum of 30 seconds, apply to the CVC exit site in a “back and forth” pattern. Then wait 60 seconds for air dry time. Clean each CVC limb and cap with a new large alcohol prep pad. Remove gloves and discard, perform hand hygiene per procedure and re-glove. Place sterile 2x2 gauze over the catheter exit site leaving connections accessible. Seal edges of gauze with tape. Apply label to the dressing indicating date dressing change was performed and initials of the teammate performing procedure. Remove gloves and discard, perform hand hygiene per procedure and re-glove. Holding catheter, place sterile 4x4 under catheter limbs. Using aseptic technique, remove each cap. One at a time, disinfect each CVC hub (the ends of the CVC connecting to the bloodlines or cap) with a new alcohol prep pad. Scrub each CVC hub for 15 seconds. Hold the limbs until dried. The Infection Control policy read, all teammates will perform hand hygiene prior to gloving and immediately after removal of gloves, after contamination with blood or other infectious material, and after patient and dialysis delivery system contact. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station. Gloves should be changed when soiled, when going from a “dirty” area or task to a “clean” area or task, and when moving from a contaminated body site to a clean body site of the same patient. 1. The facility failed to perform hand hygiene per policy prior to cleaning the CVC access site. A. Observations i. On 11/14/23 at 11:30 a.m., an observation was conducted of a CVC initiation at station #17. Patient care technician (PCT) #4 removed the gauze covering the patient’s CVC access and the gauze around the catheter limbs. PCT #4 swabbed the area on and around the CVC access for 30 seconds. Hand hygiene was not observed between these steps. ii. On 11/14/23 at 1:00 p.m., an observation was conducted of a CVC initiation at station #16. PCT #4 removed the gauze covering the patient’s CVC access and the gauze around the catheter limbs. PCT #4 swabbed the area on and around the CVC access for 30 seconds. Hand hygiene was not observed between these steps. This was in contrast to the CVC Procedure which read, teammates removed the old dressing and discarded it. Teammates removed gloves and discarded them. They performed hand hygiene per procedure and re-gloved. This was also in contrast to the Infection Control policy which read, gloves should be changed when soiled, when going from a “dirty” area or task to a “clean” area or task, and when moving from a contaminated body site to a clean body site of the same patient. B. Interviews i. On 11/15/23 at 1:49 p.m., an interview was conducted with registered nurse (RN) #2. RN #2 stated after the CVC access dressing was removed, it was expected to perform hand hygiene prior to touching any other clean supplies or clean the access site. RN #2 stated the patient was at risk for infection if staff did not perform hand hygiene after removing the CVC access dressing. ii. On 11/16/23 at 9:40 a.m., an interview was conducted with PCT #3. PCT #3 stated after the removal of the CVC access dressing prior to initiation of treatment, it was expected to perform hand hygiene prior to moving onto the cleaning of the CVC access site. PCT #3 stated it was important to change the CVC access dressing every treatment to avoid bacteria growth. PCT #3 stated the patient was at risk for having bacteria introduced into the access site and cross-contamination if staff did not perform hand hygiene after removing the CVC access dressing. iii. On 11/16/23 at 9:56 a.m., an interview was conducted with RN #6. RN #6 stated it was expected for staff to perform hand hygiene after the removal of the CVC access dressing prior to cleaning the CVC access site. RN #6 stated the patient was at risk for developing a bloodstream infection if staff did not perform hand hygiene after removing the CVC access dressing.”