Davita Chipley 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: 39374 Based on observations, interview and review of the facility’s policy and procedures, the facility staff failed to perform hand hygiene after removing gloves which creates a risk for cross-contamination. The findings include: On 8/12/2024 at 2:20 PM during an observation, Certified Clinical Hemodialysis Technician (CCHT) C was observed wearing gloves providing patient care. CCHT C moved away from the station to the supply area and removed gloves, opened the supply drawer, and retrieved a 2x2 gauze and returned to the station. No hand hygiene was performed after removing gloves or prior to retrieving the clean supplies. CCHT C returned to station, placed a 2x2 gauze on side table, performed hand hygiene and donned gloves. CCHT C placed an absorbent barrier pad on patient’s clothing over chest underneath the central venous catheter (a flexible tube inserted in the neck or upper chest and threaded to the right side of the heart) and then removing gloves and walk to supply area, opening drawer with ungloved hand and retrieving a single alcohol prep pad. CCHT C then returned to station, performed hand hygiene using hand sanitizer, and donning gloves. CCHT C then removed the old dressing from the catheter lumens (two flexible tubes used to deliver fluid or blood to and from the body) and, removed gloves, performed hand hygiene, donned gloves and opened alcohol prep pad and cleaned lumen wrapping alcohol prep around lumens cleaning from top to end of catheter lumen. CCHT C removed gloves and performed hand hygiene, opened alcohol prep pad, then using gloved hand removed the arterial hub, wrapped alcohol prep around hub and scrubbed twenty seconds. During an observation of care on 08/12/2024 at approximately 4:00PM, CCHT H was removing tubing, dialyzer, and IV bag from station #13. CCHT H discarded the equipment in the trash, removed gloves, then donned a new pair of gloves without performing hand hygiene and attached a syringe to the dialysis access line located on the patient’s right thigh who was at station #13. Following this action, CCHT H removed gloves, washed hands, then went to station #12, put on gloves and removed a clamp from the patient’s arm. After removing the clamp, CCHT H removed gloves, did not perform hand hygiene and went to the supply area, opened a drawer, returned to the patient at station #12 and removed a blood pressure cuff without performing hand hygiene. CCHT went into the water treatment area and returned to the dialysis treatment area and went to station #10 to assist a patient. CCHT H was observed charting on the computer at station #10 and assisted the patient to elevate feet in the dialysis chair, and then donned gloves without performing hand hygiene. CCHT H adjusted the machine, checked on the patient, touching his left arm, then removed gloves and walked away from station #10 without performing hand hygiene.The CCHT came back to the station with one gloved hand and adjusted the machine, removed the glove. Later in the observation, CCHT H donned a new set of gloves at station #14, touched the patient’s arm, left the station, removed gloves without performing hand hygiene, got a roll of tape and returned to station #14, donned a new set of gloves and applied tape to the patient’s left upper arm access site, assisted the resident up and out of chair. Then, wearing the same gloves, went to get cleaning supplies to clean the station. In an interview with CCHT H on 08/12/2024, following these observations, she explained the policy for hand hygiene is to use hand sanitizer (alcohol based hand rub) up to three times and then wash your hands. She confirmed she had not sanitized her hands each time between glove use. A review of company policy 1-05-01 “Infection Control For Dialysis Facilities,” Origination Date: September 2007, Revision Date: April 2023 indicates that all staff will perform hand hygiene prior to gloving and immediately after removal of gloves, and before touching clean areas such as supplies and supply cart.”

“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: 39374 Based on observation, interview,and policy review, the facility failed to ensure equipment was operated in accordance with facility instructions for one of one patients in the facility who require hoyer lift transfer assistance (Patient #5). The findings include: On 08/12/2024 at 10:34 AM observed Patient Care Technician (PCT) E transferring Patient #5 from the dialysis chair to his wheel chair using a hoyer lift (a mechanical patient lift device which places the patient in a sling to transfer from one area to another). During this observation, there were several other care team members on the dialysis floor. PCT E did not receive or ask for assistance in transferring Patient #5 to the wheelchair. Following the observation, PCT E said in an interview he was trained to operate the hoyer lift with two staff members, but everyone was busy, so he did it by himself. On 08/12/2024 at 11:33AM during an interview, the charge nurse, registered nurse (RN) A said Patient #5 is the only patient who requires use of the hoyer lift and is always a 2-person transfer. She explained failure to follow the 2-person operation is considered a “risk event management” or “REM” reportable item. Review of facility policy 4-08-18 with a most recent revision date of April 2023, included the phrase “Two (2) teammates are required when utilizing mechanical lift devices.” According to a “Patient Lifts Safety Guide” published by the Food and Drug Administration (FDA) and accessed on 08/16/2024 at 8:11AM at https://www.fda.gov/files/medical%20devices/published/Patient-Lifts-Safety-Guide.pdf, “Most lifts require two or more caregivers to safely operate lift and handle patient.” The guide also included information that “patient falls from lifts may cause injuries, including head trauma, fractures, and death.””