Usrc North Tampa 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: 34768 Based on observation, interview and record review the facility failed to follow infection control protocols related to hand sanitizing between donning and doffing of gloves during care for various dialysis patients in 2 of 2 observations. Findings included: Observation on 11/12/2024 from 9:10 a.m. until 11:30 a.m. Staff A, Patient Care Technician (PCT) was observed not consistently hand sanitizing between glove changes while providing care for various dialysis patients. During an interview on 11/13/2024 at 12:00 p.m. the Facility Administrator stated that staff were educated on hand hygiene and infection control monthly during the “huddle meetings”. She stated if a staff member was covering in their facility, they would obtain the education from their home facility. She stated all staff members were to hand sanitize between glove changes. On 11/12/2024 at 9:57 a.m., during a discussion with Staff A, PCT, regarding the next chlorine water test being done, the alarm device was observed with a digital read out and revealed 00:00. Staff C, Registered Nurse (RN) confirmed the alarm needed to be set. Staff A, PCT revealed she often times will forget to use and set the alarm located on the nurse station desk and just uses her personal phone to remind her. Staff A was asked when the next time the water chlorine test needed to be conducted, and she was observed to put her bare hand in her front pocket and pulled out her personal phone. She used her bare fingers to press buttons to unlock the phone and then revealed per her phone, they still have two and a half hours left before the next water chlorine test. Staff C, RN was observed shaking her head in a “no” manner and revealed that the timer on the nurse station needs to be set every time and staff should not be using their personal phone as the primary timer. Staff C, RN then reset the clock alarm timer device on the nurse station for two and a half hours. During the same time, Staff A, PCT pressed more buttons on her personal phone with her bare hand and put it back in her front pocket. Staff A, PCT immediately went to station number twelve, where there was a patient seated in a dialysis chair. Staff A, PCT touched the Dialysis machine screen with her bare hand and then touched the patient’s arm and wrist and walked away. Staff A, PCT did not wash her hands and or glove prior to touching her phone and then the patient. Staff A, PCT walked to an area at the nurse station and grabbed supplies with her bare hands. Staff A, PCT then washed and donned gloves after putting the supplies at an empty Dialysis station/chair. Review of the facility’s policy, “Hand Hygiene,” revised 08/2020 showed to give guidance on proper hand hygiene and avoid the transmission of harmful germs and prevent healthcare- associated infections. Hand hygiene will be performed: 1. Before and after touching a patient. 2. Prior to entering and on exiting station to provide care to patient. 3. Prior to contact with vascular access site. 8. After touching patient surroundings. 9. After gloves are removed 10. Before and after touching PPE. 11. After contact with inanimate objects, including medical equipment or environmental surfaces in the patient station. 12. Before entering and on exiting the patient treatment areas. 13. When moving from a contaminated body site to a clean body site of the same patient.”

“LAB-CLIA LABS/MEET NEEDS OF PTS CFR(s): 494.130 The dialysis facility must provide or make available, laboratory services (other than tissue pathology and histocompatibility) to meet the needs of the ESRD patient. Any laboratory services, including tissue pathology and histocompatibility must be furnished by or obtained from, a facility that meets the requirements for laboratory services specified in part 493 of this chapter. This Standard is not met as evidenced by: 34768 Based on observation and interviews the facility failed to ensure laboratory supplies were within the expiration date in accordance with CFR 493 on 3 (11/12/2024, 11/13/2024 9:45am and 11:40pm) of 3 observations . Findings included: On 11/12/2024 at 8:55 a.m. the supplies cabinet/cupboard and sink/counter area located between the Facility Administrator’s office and the door leading to other administrative offices was observed with the back wall lined with cabinets and a doorless cubby area with two shelves. The doorless cubby area was observed with supplies stacked on the first and second shelf. The top shelf was observed with unopened packages of Vacutainers; one package was observed with 100 count Vacutainer blood tubes with pink/maroon colored caps. The other package was observed with 100 count Vacutainer blood tubes with yellow colored caps. The unopened package of yellow capped Vacutainers blood collection tubes were observed with an expired date of 10/31/2024. These Vacutainers were set on the shelf for use. (Photographic evidence obtained). On 11/13/2024 at 9:45 a.m. and 11:40 a.m. the expired package of Vacutainers were still observed on the second shelf of the cubby area, on the treatment floor. On 11/13/2024 at 12:00 p.m. an interview with the Facility Administrator revealed Staff B, Administrative Assistant is the primary staff member responsible for the ordering and restocking of supplies. She revealed Staff B is also responsible for identifying if any of the supplies are expired and will remove them from the treatment floor area and discard them. The Facility Administrator stated that any staff who identifies expired supplies, are to remove them and either show the Clinical Care Manager, the Administrative Assistant or the Facility Administrator. On 11/13/2024 at 12:20 p.m. an interview with Staff B, Administrative Assistant confirmed it is her responsibility to stock and remove expired supplies to include Vacutainer Blood Collection tubes. She was not aware there were any Vacutainers that were on the shelves and that were expired.”