062554 Kidney Center of Arvada (Ara)

“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, staff interviews, and document review, the facility failed to ensure five of six 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 - 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 six observations of dialysis station cleaning.”

“CFC-PHYSICAL ENVIRONMENT CFR(s): 494.60 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 §494.60 Physical environment was out of compliance. V403 - Equipment maintenance. 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. Based on observations, document review, and staff interviews the facility failed to implement and maintain a program to ensure that all equipment was maintained in accordance with facility policy. Specifically, 10 out of 21 treatment chairs had torn surfaces in the seat cushion, which created the potential for infection or cross-contamination between patients in the dialysis facility.”

“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, staff interviews, and document review, the facility failed to ensure five of six 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 Infection Control policy read, the purpose of this policy is to decrease the potential for spread of infection within Innovative Renal Care and American Renal Associates care centers (IRC/ARA). IRC/ARA’s policies for infection control are based on the “recommendations for preventing transmission of infections among Chronic hemodialysis patients” developed by the Centers for Disease Control and prevention. Patients will be educated and encouraged to wear gloves when holding their access sites, and wash hands before entering and leaving the patient treatment area. 1. The facility failed to ensure patients performed hand hygiene following the removal of soiled gloves. A. Observations i. On 1/31/24 at 10:13 a.m., an observation was conducted at station # 14. The patient was observed holding pressure to their own access site with a gloved hand following the removal of the needles used for treatment. After stabilization of the site, a staff member applied a dressing to the site. The patient then removed the glove, and without performing hand hygiene, packed their belongings and went to the scale for a post-treatment weight check The patient’s access site was observed to be dripping blood, was taken back to their dialysis chair where staff cleaned the access area, changed the dressing and held the area until it stopped bleeding. The patient again went to the scale where staff obtained their post dialysis weight and the patient then left the facility. The patient was observed touching the door upon exit. Staff members did not educate or request the patient perform hand hygiene following glove removal. ii. On 1/31/24 at 9:34 a.m., an observation was conducted at station #7. The patient was observed holding pressure to their own access site with a gloved hand following the removal of the needles used for treatment. After stabilization of the site, a staff member applied a dressing to the site. The patient then removed the glove, and without performing hand hygiene, packed their belongings, went to the scale for a post-treatment weight check, and left the facility. The patient was observed touching the door upon exit. Staff members did not educate or request the patient perform hand hygiene following glove removal. iii. On 1/31/24 at 9:47 a.m., an observation was conducted at station #17. The patient was observed holding pressure to their own access site with a gloved hand following the removal of the needles used for treatment. After stabilization of the site, a staff member applied a dressing to the site. The patient then removed the glove, and without performing hand hygiene, packed their belongings, went to the scale for a post-treatment weight check, and left the facility. The patient was observed touching the door upon exit. Staff members did not educate or request the patient perform hand hygiene following glove removal. iv. On 1/31/24 at 9:57 a.m., an observation was conducted at station #13. The patient was observed holding pressure to their own access site with a gloved hand following the removal of the needles used for treatment. After stabilization of the site, a staff member applied a dressing to the site. The patient then removed the glove, and without performing hand hygiene, packed their belongings, went to the scale for a post-treatment weight check, and left the facility. The patient was observed touching the door upon exit. Staff members did not educate or request the patient perform hand hygiene following glove removal. v. On 1/31/24 at 9:54 a.m., an observation was conducted at station #9. The patient was observed holding pressure to their own access site with a gloved hand following the removal of the needles used for treatment. After stabilization of the site, a staff member applied a dressing to the site. The patient then removed the glove, and without performing hand hygiene, packed their belongings, went to the scale for a post-treatment weight check, and left the facility. The patient was observed touching the door upon exit. Staff members did not educate or request the patient perform hand hygiene following glove removal. The observations were in contrast to facility policy which read, patients would be encouraged to perform hand hygiene after treatment before leaving the treatment area. B. Interviews i. On 2/5/24 at 11:37 a.m., an interview was conducted with patient care technician (PCT) #1. PCT #1 stated stated after the patient’s access site was stabilized, the patient was to remove their glove and perform hand hygiene. PCT #1 stated there was a risk of the patient having blood on their hand which could have been an infection risk. ii. On 2/5/24 at 10:53 a.m., an interview was conducted with registered nurse (RN) #2. RN #2 stated after glove removal, patients were to use a wet wipe, wash with soap and water at the sink or use hand sanitizer for hand hygiene. RN #1 stated if a patient did not perform hand hygiene after glove removal there was a risk of infection. iii. On 2/5/24 at 11:20 a.m., an interview was conducted with clinic manager (Manager) #3. Manager #3 stated patients were to perform hand hygiene after holding their sites because blood was a body fluid and there was a risk of infection to others in the facility.”

“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 six observations of dialysis station cleaning. Findings include: Facility policy: The Cleaning and Disinfection of Equipment, Supplies, and Treatment Area policy read, the purpose of this policy is to prevent transmission of infectious agents in the dialysis center. Equipment, treatment area, and work surfaces will be disinfected using a 1:100 bleach/water solution with disposable cloths. All routinely touched reusable equipment and surfaces in each patient’s treatment area are disinfected after each patient’s treatment. Caregivers will ensure that cracks/crevices come in contact with the bleach solution. 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 clean and disinfect the dialysis chair between patient treatments according to facility policy. Direct patient care staff did not allow all surfaces of the dialysis chair to completely air dry after surfaces were wiped with a bleach solution before closing the chair. A. Observations i. On 1/31/24 at 3:12 p.m., an observation was conducted at station #1. The dialysis chair was observed to be visibly wet, with both side arms fully closed. The gap between the chair arms and the side of the chair was observed to be glistening wet. Patient care technician (PCT) #1 was observed closing the chair while still wet with the bleach solution. PCT #1 was asked if the chair was wet or dry and they verified the chair was wet. ii. On 1/31/24 at 3:13 p.m., PCT #1 was observed as they disinfected the chair in station #2. PCT #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 both chair side arms while the chair remained visibly wet. iii. On 2/1/24 at 10:57 a.m., PCT #5 was observed as they disinfected the chair in station #2. PCT #5 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 right chair side arm while the chair remained visibly wet. B. Interviews i. On 2/5/24 at 11:37 a.m., an interview was conducted with PCT #1. PCT #1 stated dialysis chairs were to remain fully reclined and arms open until the chair was dry. PCT #1 states it was facility policy but was unsure if there was a risk to the patient if the policy was not followed. This was in contrast with the observation of PCT #1 which revealed the dialysis chair was not fully reclined during the cleaning process ii. On 2/5/24 at 10:53 a.m., an interview was conducted with registered nurse (RN) #2. RN #2 stated after the dialysis chairs were cleaned they were to remain fully reclined and the arms left open until the chair was dry. RN #2 stated the chair was to remain open so the bleach used to clean the chairs could fully disinfect the chair. RN #2 stated if the bleach was not allowed to fully disinfect the chairs there was a risk of infection.”

“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: 45020 Based on observations, document review, and staff interviews the facility failed to implement and maintain a program to ensure that all equipment was maintained in accordance with facility policy. Specifically, 10 out of 21 treatment chairs had torn surfaces in the seat cushion, which created the potential for infection or cross-contamination between patients in the dialysis facility. Findings include: Facility policy: The Technical Service policy read, all dialysis chairs will be inspected monthly for the following: Torn upholstery, stains, and damage. All dialysis chairs will be repaired or replaced, as needed based upon the monthly inspection. 1. The facility failed to maintain and repair patient treatment chairs to allow effective cleaning and disinfection. a. A tour of the patient treatment area on 1/31/24 revealed 10 out of 21 dialysis treatment chairs had torn surfaces on the seat cushion which had not been effectively repaired. The torn surfaces did not allow effective disinfection due to the broken surfaces. For example: i. Station #4’s patient dialysis chair was noted to have a large rip in the seat cushion, which measured approximately 12 inches long. ii. Station #10’s patient dialysis chair was noted to have a large rip in the seat cushion, which measured approximately 12 inches long. iii. Station #21, an isolation room (a separate area for dialyzing patients with certain infections or medical conditions), was noted to have a small rip in the seat cushion, which measured 1-2 inches long. iv. Multiple other dialysis chairs were noted to have torn, ripped, and open areas in the seat cushions. a. On 2/5/24 at 10:53 a.m., an interview was conducted with registered nurse (RN) #2. RN #2 stated they were aware some of the dialysis chairs were ripped. RN #2 stated dialysis chairs were cleaned with a bleach solution after each patient to remove any bacteria and blood spills to prevent the spread of infection. RN #2 stated they were unsure if a dialysis chair could be effectively cleaned if there was a rip or tear and there was a risk of infection. b. On 2/5/24 at 11:20 a.m., an interview was conducted with clinic manager (Manager) #3. Manager #3 stated audits performed in the facility did not include dialysis chairs. Manager #3 stated they were aware some of the dialysis chairs needed repair and stated there was no risk to the patients. c. On 2/5/24 at 10:19 a.m., an interview was conducted with medical director (Director) #4. Director #4 stated they were not notified or aware the dialysis chairs were ripped. Director # stated there was a risk if the chair covers were ripped, which was an infection risk because the chairs could not be properly cleaned.”