062548 Stapleton Dialysis (Fmc)

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 45020 Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §494.30 Infection Control, was out of compliance. V113 - 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. Based on observations, interviews, and review of the facility’s policy, the facility failed to ensure seven of seven patients, who were observed holding pressure to their access sites (locations where needles were inserted and then removed for treatment), performed hand hygiene following the removal of soiled gloves and prior to leaving the facility. V122 - [Standard: Procedures for infection control. The facility must demonstrate that it follows standard infection control precautions by implementing-] [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. 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 three of four observations of dialysis station cleaning. Specifically, staff did not fully recline the dialysis chair to ensure all surfaces were cleaned.”

“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: 45020 Based on observations, interviews, and review of the facility’s policy, the facility failed to ensure seven of seven patients, who were observed holding pressure to their access sites (locations where needles were inserted and then removed for treatment), performed hand hygiene following the removal of soiled gloves and prior to leaving the facility. Findings include: Facility policy: The Hand Hygiene policy read, the purpose of this policy is to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination. All staff, patients, patient care givers, including physicians and non-physician practitioners, social workers, dietitians, and any other indirect patient care staff must follow the same requirements for hand hygiene. Hand Hygiene: Patients: Patients should perform hand hygiene if able, prior to and after each dialysis treatment. As needed, direct patient care staff will demonstrate how to operate the sinks, demonstrate hand washing to patients who are able to perform hand washing, and explain risk of contamination with regard to their vascular access and hands to all patients. Gloves must be provided to patients when performing procedures which risk exposure to blood or body fluids, such as when self-cannulating or holding access sites post treatment to achieve hemostasis. To help ensure the prevention of cross contamination to their family members or other patients, hand hygiene must be performed. 1. The facility failed to ensure patients performed hand hygiene following the removal of soiled gloves. A. Observations i. On 2/27/25 at 9:00 a.m., an observation was conducted at station #17. The patient was observed holding pressure to their access sites with a gloved right hand following the removal of the needles used for treatment. After stabilization of the site, patient care technician (PCT) #1 changed the dressing, the patient removed the glove from their right hand, gathered their belongings and ambulated to the scale. The patient touched the button on the scale to obtain their weight and left the treatment floor. Staff did not educate or request the patient to perform hand hygiene following the glove removal. ii. On 2/27/25 at 9:11 a.m., an observation was conducted at station #6. The patient was observed holding pressure to their access site with a gloved right hand following the removal of the needles used for treatment. At 9:26 a.m., PCT #2 changed the dressing to the access site. The patient gathered their belongings and ambulated to the scale with the glove on their right hand, removed the glove at the scale, obtained their weight and exited the treatment floor. Staff did not educate or request the patient to perform hand hygiene following the glove removal. iii. On 2/27/25 at 9:20 a.m., an observation was conducted at station #1. The patient was observed holding pressure to their access site with a gloved right hand following the removal of the needles used for treatment. At 9:21 a.m., the patient gathered their belongings, ambulated to the scale, touched the scale with their gloved right hand to obtain their weight, then removed the glove and left the treatment floor. Staff did not educate or request the patient to perform hand hygiene following their glove removal. iv. On 2/27/25 at 9:58 a.m., an observation was conducted of a patient leaving station #5. The patient was observed ambulating to the scale with a glove on their right hand. The patient touched the scale to obtain their weight with their gloved right hand, then exited the treatment floor with the glove on. Staff did not educate or request the patient to perform hand hygiene, or request glove removal before leaving the treatment area. v. On 2/27/25 at 10:50 a.m., an observation was conducted at station #15. The patient was observed holding pressure to their access site with a gloved right hand following the removal of the needles used for treatment. At 11:17 a.m., registered nurse (RN) #3 changed the dressing to the access site. The patient gathered their belongings, ambulated to the scale, touched the scale with their gloved right hand to obtain their weight, and then exited the treatment floor with the glove remaining on their right hand. Staff did not educate or request the patient to perform hand hygiene, or request glove removal before leaving the treatment area. vi. On 3/3/25 at 10:00 a.m., an observation was conducted at station #20. The patient was observed holding pressure to their access site with a gloved right hand. At 10:11 a.m., the patient’s access sites were visibly bleeding through the dressing. PCT #2 changed the dressing and the patient held pressure to their access sites again. At 10:18 a.m., PCT #2 reinforced the dressing. The patient removed the glove, gathered their belongings, ambulated to the scale, obtained their weight and left the treatment floor. Staff did not educate or request the patient to perform hand hygiene following their glove removal. vii. On 3/3/25 at 10:13 a.m., an observation was conducted at station #15. The patient was observed holding pressure to their access site with a gloved right hand, the access site was visibly bleeding through the dressing. PCT #4 changed the dressing and the patient held pressure to their access sites again. At 10:23 a.m., PCT #4 reinforced the dressing. The patient removed the glove, gathered their belongings, ambulated to the scale, obtained their weight and left the treatment floor. Staff did not educate or request the patient to perform hand hygiene following the glove removal. B. Interviews i. On 3/3/25 at 1:54 p.m., an interview was conducted with PCT #2. PCT #2 stated after the patient’s access site was stabilized, the patient was to remove their glove and perform hand hygiene. PCT #2 stated if hand hygiene was not performed by the patient after holding their access sites there was a risk of contamination, infection and hepatitis (a serious liver infection). ii. On 3/4/25 at 11:08 a.m., an interview was conducted with PCT #5. PCT #5 stated after the patient’s access site was stabilized, the patient was to remove their glove and perform hand hygiene. PCT #5 stated there was a risk of cross-contamination if patients did not perform hand hygiene per policy, which could cause hepatitis, HIV (Human Immunodeficiency Virus)(a virus that attacks and weakens the body’s immune system) and infection, which could cause death. iii. On 3/4/25 at 1:12 p.m., an interview was conducted with RN #7. RN #7 stated patients were to perform hand hygiene when they entered the treatment area and again before leaving the treatment area. RN #7 stated if a patient did not perform hand hygiene after glove removal there was a risk of infection, which could cause sepsis (bloodstream infection) and infection.”

“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 three of four observations of dialysis station cleaning. Specifically, staff did not fully recline the dialysis chair to ensure all surfaces were cleaned. Findings include: Facility policy: The Cleaning and Disinfection of the Dialysis Station policy read, 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 environment for patients, staff and visitors. The Centers for Medicare and Medicaid Services (CMS) has regulations that in order to prevent cross contamination, a dialysis station must be cleaned and disinfected between dialysis patients. The chair and dialysis equipment are used by multiple patients during a treatment day and it is critical that these items be thoroughly cleaned and disinfected between uses. The steps to disinfect the dialysis station, which includes the dialysis chair, machine, television, IV pole, blood pressure cuff, hand sanitizer dispenser and holder, chaise wall behind chair. Place the chair in Trendelenburg position (flat on the back with the feet elevated above the head) and open side panels if the chair has swing open sides so all surfaces are accessible. Clean all surfaces. Make the surfaces glisteningly wet and allow to air dry. 1. The facility failed to ensure dialysis chairs were cleaned and disinfected between patient treatments according to facility policy. Direct patient care staff did not place the dialysis chair into the fully reclined position to ensure all surfaces of the chair were cleaned. A. Observations i. On 2/27/25 at 9:11 a.m., patient care technician (PCT) #6 was observed as they disinfected the dialysis chair at station #9. PCT #6 wiped all visible surfaces of the chair with a bleach solution and opened the side armrests to clean and disinfect the surfaces in between the chair and the armrest, however, they did not place the chair into a fully reclined position to wipe the crevices of the chair seat. After completing the dialysis chair disinfection, PCT #6 was asked if the head of the dialysis chair reclined further, and PCT #6 stated it did. PCT #6 pulled a lever located on the back of the chair and fully reclined the dialysis chair, then pulled the head of the chair back up while the dialysis chair continued to dry. ii. On 2/27/25 at 11:38 a.m., PCT #1 was observed as they disinfected the dialysis chair at station #19. PCT #1 wiped all visible surfaces of the chair with a bleach solution and opened the side armrests to clean and disinfect the surfaces in between the chair and the armrest, however, they did not place the chair into a fully reclined position to wipe the crevices of the chair seat. After completing the dialysis chair disinfection, PCT #1 was asked if the head of the dialysis chair reclined further, and PCT #1 stated it did. PCT #1 pulled a lever located on the back of the chair and fully reclined the dialysis chair, then pulled the head of the chair back up while the dialysis chair continued to dry. iii. On 3/3/25 at 9:06 a.m., PCT #4 was observed as they disinfected the dialysis chair at station #13. PCT #4 wiped all visible surfaces of the chair with a bleach solution and opened the side armrests to clean and disinfect the surfaces in between the chair and the armrest, however, they did not place the chair into a fully reclined position to wipe the crevices of the chair seat. After completing the dialysis chair disinfection, PCT #4 was asked if the head of the dialysis chair reclined further, and PCT #4 stated it did. PCT #4 pulled a lever located on the back of the chair and fully reclined the dialysis chair. These observations were in contrast to the Cleaning and Disinfection of the Dialysis Station policy, which read, place the chair in Trendelenburg position so all surfaces were accessible. B. Interviews i. On 3/3/25 at 1:54 p.m., an interview was conducted with PCT #2. PCT #2 stated the process for a dialysis chair to be cleaned was to pull the lever on the back of the chair to completely recline it. PCT #2 stated it was important to clean dialysis chairs thoroughly between patients because there was a risk of infection. ii. On 3/4/25 at 11:08 a.m., an interview was conducted with PCT #5. PCT #5 stated the process for a dialysis chair to be cleaned was to pull the lever on the back of the chair to completely recline it. PCT #5 stated dialysis chairs were disinfected between patients because it prevented and minimized the risk of infection. iii. On 3/4/25 at 1:12 p.m., an interview was conducted with registered nurse (RN) #7. RN #7 stated dialysis chairs were to be cleaned after each use. RN #7 stated dialysis chairs were to be fully reclined with a lever on the back of the chair to ensure the crevice was fully disinfected. RN #7 stated if dialysis chairs were not cleaned per policy, there was an infection risk to the patients, which could cause death. These interviews were in contrast to the observations which revealed dialysis chairs were not fully reclined when cleaned and disinfected.”