Davita Northeastern Colorado Diaysis

“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 document review, the facility failed to ensure three of four patients 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 one of three observations of dialysis station cleaning. Specifically, staff did not allow the chair to fully dry.”

“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 document review, the facility failed to ensure three of four patients 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 for Dialysis Facilities policy read, the purpose of this policy is to minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. Patients and caregivers will be encouraged to perform hand hygiene after treatment before leaving the treatment area. 1. The facility failed to ensure patients performed hand hygiene following the removal of soiled gloves. A. Observations i. On 5/28/24 at 3:51 p.m., an observation was conducted at station #10. The patient was observed holding pressure to their own site with a gloved hand following the removal of the needles used for treatment. After stabilization of the site, patient care technician (PCT) #1 applied a dressing to the site. The patient then removed the soiled glove and, without performing hand hygiene, packed their belongings, weighed themselves at the scale and left the facility. PCT #1 did not educate or request the patient to perform hand hygiene following glove removal. ii. On 5/28/24 at 4:15 p.m., an observation was conducted at station #12. The patient’s caregiver was observed holding pressure with a gloved hand following the removal of the needles used for treatment. After stabilization of the site, PCT #1 applied a dressing to the site. The patient’s caregiver then removed the soiled glove and, without performing hand hygiene, packed the patient’s belongings,and left the facility. PCT #1 did not educate or request the patient’s caregiver to perform hand hygiene following glove removal. iii. On 5/29/24 at 9:30 a.m., an observation was conducted at station #8. The patient was observed holding pressure to their own site with a gloved hand following removal of the needles used for treatment. After stabilization of the site, PCT #2 applied a dressing to the site. The patient then removed the soiled glove and, without performing hand hygiene, packed their belongings and left the facility. PCT #2 did not educate or request the patient to perform hand hygiene following glove removal. B. Interviews i. On 5/30/24 at 8:38 a.m., an interview was conducted with PCT #4. PCT #4 stated after the patient’s access site was stabilized, the patient was to remove their glove and perform hand hygiene. PCT #4 stated if a patient did not perform hand hygiene after glove removal there was a risk of infection. ii. On 5/30/24 at 8:18 a.m., an interview was conducted with registered nurse (RN) #3. RN #3 stated after the patient’s access site was stabilized, the patient was to remove their glove and perform hand hygiene. RN #3 stated hand hygiene was important for patients because there was a risk of transferring viruses to others, including blood stream infections which could cause death. This was in contrast to facility policy which read, patients and caregivers would be encouraged to perform hand hygiene after treatment before leaving the treatment area.”

“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 three 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 dialysis chairs were cleaned and disinfected between patient treatments according to facility policy. Direct patient care staff did not leave the dialysis chair fully open to ensure all surfaces were disinfected. A. Observations i. On 5/28/24 at 10:20 a.m., PCT #2 was observed as they disinfected the dialysis chair in station #7. PCT #2 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 side arm while the chair remained visibly wet. B. Interviews i. On 5/30/24 at 8:18 a.m., an interview was conducted with registered nurse (RN) #3. RN #3 stated dialysis chairs were to be fully reclined, side arms opened, and all surfaces cleaned with a bleach solution. RN #3 further stated the chair’s arms were to be left open until dry. RN #3 stated it was important for patient chairs to be cleaned with bleach between patient use between patients because it prevented and minimized the risk of infection. ii. On 5/30/24 at 9:14 a.m., an interview was conducted with patient care technician (PCT) #2. PCT #2 stated dialysis chairs were to be fully reclined with side arms opened and all surfaces were to be cleaned with a bleach solution. PCT #2 stated bleach was used to kill any bacteria and if the chair were to be closed while wet, bacteria could grow. PCT #2 stated it was important to clean dialysis chairs between patients because there was a risk of infection, which could cause hospitalization or death. These interviews were in contrast to the observations which revealed a dialysis chair was not fully dry when closed.”