Davita Tallahassee South Dialysis

“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: 45827 Based on observation, review of facility policy and procedure and interview, the facility failed to ensure staff removed gloves and completed hand hygiene between each station for 1 of 2 observations of cleaning dialysis stations. The findings include: On 11/18/24 beginning at approximately 2:15 PM an observation was conducted of Staff D, a Patient Care Technician, cleaning Station #5. During the process, the dialysis machine at Station #6 began to alarm during the patient’s dialysis. Staff D stopped cleaning Station #5, walked to Station #6 and silenced the alarm on the dialysis machine without changing her gloves or performing hand hygiene. Staff D resumed cleaning Station #5 wearing the same gloves. At approximately 2:19 PM, the dialysis machine at Station #6 began to alarm again. Staff D stopped cleaning Station #5, walked to Station #6 and silenced the alarm without changing her gloves or performing hand hygiene. Staff D then resumed cleaning Station #5 wearing the same gloves. A review of the facility’s policy and procedure 1-05-01 states on Page 2, #7 (a) Gloves should be changed when: iv. After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient’s dialysis delivery system. On 11/19/24 at approximately 12:30 PM an interview was conducted with Staff D who stated her gloves should have been removed, hand hygiene performed, and clean gloves put on before touching the dialysis machine at Station #6 since she was cleaning Station #5. Staff D further stated this was not done because she was in a hurry wanted to check the alarm quickly.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 45827 Based on observations, review of facility policy and procedure and interviews, the facility failed to ensure staff disinfected their stethoscopes after patient contact for 2 of 4 staff providing patient care. (Staff A and Staff B). The findings include: On 11/18/24 at approximately 11:40 AM, Staff A, a Patient Care Technician was observed to use a stethoscope on the patient at Station #1 then, without cleaning it, hang the stethoscope on a peg near other stethoscopes. On 11/18/24 at approximately 2:36 PM, Staff B, a Registered Nurse, was observed to use a stethoscope on the patient at Station #6 then replace the stethoscope around her neck without cleaning it. Staff B was then observed to walk over to the patient at Station #14 with the stethoscope still around her neck then proceeded to walk to the desk and use the telephone with the stethoscope still around her neck. A review of the facility’s policy and procedure 1-05-01 - Infection Control for Dialysis Facilities states on Page 4, #14 Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between uses. (a) Stethoscopes will be disinfected with alcohol prep pad and/or 1:100 bleach solution ... On 11/19/24 at approximately 9:00 AM an interview was conducted with Staff A who stated the stethoscope did not need to be cleaned before hanging it up but had to be cleaned before using it on a patient. On 11/19/2424 at approximately 9:15 AM an interview was conducted with Staff B who stated the stethoscope should be cleaned after it is used on a patient and before going to another patient’s station.”

“IC-HBV-TEST PTS/STAFF POST LAST DOSE CFR(s): 494.30(a)(1)(i) Hepatitis B Screening: Patients and Staff Test all vaccines [patients and staff] for anti-HBs 1-2 months after last primary vaccine dose. -- If anti-HBs is <10 mIU/mL, consider patient or staff member susceptible, revaccinate with an additional three doses, and retest for anti-HBs. -- If anti-HBs are =10 mIU/mL, consider immune, and retest patients annually. -- Give booster dose of vaccine to patients if anti-HBs declines to <10 mIU/mL and continue to retest patients annually. This Standard is not met as evidenced by: 45951 Based on record review and interview, the facility failed to ensure all employees received Hepatitis B immunity testing in a timely manner for 1 of 3 employees reviewed for vaccination status and immunity testing (Staff C). The findings included: During the employee record review, the surveyor reviewed three employee’s files for vaccination status and Hepatitis B immunity testing. The surveyor was unable to locate the Hepatitis B immunity testing for Staff C, Patient Care Technician. The surveyor noted Staff C had been employed at the facility since 08/21/23. In an interview conducted with the Facility Administrator (FA) and the Senior Manager of Clinical Services, both were able to independently review Staff C’s employee file. Both were unable to locate Staff C’s Hepatitis B immunity testing results. The Senior Manager of Clinical Services stated facility policy stated the immunity testing was supposed to be drawn shortly after an employee was hired. She further stated there had been multiple attempts to draw Staff C’s immunity since her hire but that it never happened. She said they had not been concerned to draw Staff C’s immunity because the facility had no Hepatitis B positive patients. She and the FA confirmed Staff C had the ability to “float” and work at other clinics. The surveyor explained the concern was that there could be Hepatitis B positive patients at other clinics that Staff C was floating to.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 45827 Based on observations, review of facility policy and procedure and interviews, the facility failed to ensure the Central Venous Catheters (CVC) (a thin, flexible tube that is inserted into a vein, usually below the right collarbone, and guided into a large vein above the right side of the heart) were properly cleaned and hands were sanitized between glove changes for 2 of 2 observations performed (Station #10 and Station #6). The findings include: On 11/19/24 beginning at approximately 10:16 AM, Staff C, a Patient Care Technician, was observed to provide CVC exit site care and initiate the patient for dialysis at Station #10. Staff C did not cleanse each CVC limb/cap prior to accessing and did not sanitize hands between glove changes during the procedure. On 11/19/24 beginning at approximately 10:40 AM, Staff C was observed to provide CVC exit site care and initiate the patient for dialysis at Station #6. Staff C did not cleanse each limb/cap prior to accessing and did not sanitize hands between glove changes during the procedure. A review of the facility’s policy and procedure 1-04-02B Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure states on Page 4, #9 Clean each CVC limb/cap with a new large alcohol prep pad, starting close to the exit site and finishing with the cap. The policy also states on Page 4, #7 and Page 5, #10 and #14 Remove gloves and discard. Perform hand hygiene per procedure and re-glove. On 11/19/24 at approximately 11:45 AM, an interview was conducted with the Senior Manager of Clinical Services who stated the CVC caps should be cleaned prior to accessing. On 11/19/24 at approximately 12:00 PM, an interview was conducted with Staff C who stated she was nervous and forgot to clean the CVC caps. She further stated she should have sanitized her hands between each glove change during both procedures, but she was crunched for time.”