Nulife Dialysis Inc.

“IC-CATHETERS:GENERAL CFR(s): 494.30(c)(2) (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection as the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html This Standard is not met as evidenced by: 47207 Based on observations and interviews, the facility failed to ensure that Staff followed infection control guidelines when caring for the patient or touching the patient’s equipment at the dialysis station for 2 out of 9 Sampled Patients (SP). SP#4 and SP#5 Findings include: Patient Care Technician (PCT) 1 was observed on 02/21/2024 at 9:30 AM starting the process of decannulating SP#4. PCT1 performed hand hygiene and put on new gloves, he then disconnected the blood lines aseptically and went on to remove one of the needles and activated the retraction device he applied a bandage and clean gauze to the site, PCT1 then applied a clean clamp to the site. PCT1 then removed his gloves, performed proper hand hygiene, and donned new gloves; he did not offer a glove to the patient. PCT1 then removed the second needle applying a bandage and gauze to the site. SP#4 was observed holding the clean dressing of his fistula sites with his bare hand. The surveyor brought this to the attention of the Registered Nurse in charge (RN1) who also observed the events. RN1 then spoke to the staff member who at this time applied a glove to the SP#4’s hand. At this time, SP#4 was on the scale and leaving the facility. RN1 stated the PCT1 was nervous that someone was watching him. PCT1 was then observed decannulating SP#5 on 02/21/2024 at 10:00 AM, he again performed hand hygiene prior to starting the process and put on new gloves. PCT1 disconnected one blood line aseptically and removed the needle aseptically and activated the needle retraction device and discarded the needle. At this point SP#5 raised her left hand, the unaffected arm asking PCT1 to provide her with a glove to that hand, which he did. RN1 spoke with PCT1, the PCT stated that he had been nervous having someone watch him. During an interview conducted on 02/21/2024 at 2:30 PM, the Facility Administrator and DON acknowleged the above findings.”

“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: 47207 Based on observation and interview, the facility failed to implement and maintain a program to ensure the equipment (including emergency equipment, machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. The facility failed to ensure there were no expired laboratory tubes available for use. Findings include: An observation of the laboratory area on 2/20/2024 at 9:40 AM revealed 2 packages, one of which appeared to have been opened, of test tubes colored green with yellow rib on top with an expiration date of 06/15/2023 available for use in the specimen collection cabinet. An interview was conducted with the Facility Administrator (FA) and Director of Nursing (DON) on 2/20/2024 at 9:50 AM, both stated that they had changed laboratories, and these were from the previous laboratories’ supplies. The DON further stated that he had asked one of the technicians to check to make sure all expired products had been discarded.”