Crisp Regional Hospital Dialysis Unit

“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: 03383 Based on observation, a review of the Centers for Disease Control and Prevention (CDC) recommendations, staff interview, and review of policy and procedures, it was determined that the Infection Control Committee failed to ensure that five of six patients observed at Station (S) 1, S8, S9, S10, and S13 who held pressure to their access sites for hemostasis (stopping of the flow of blood) after dialysis, performed hand hygiene (wash hands with soap and water or use an alcohol based hand sanitizer) after glove removal and prior to leaving the treatment area. This deficient practice had the potential for cross contamination. The facility had 51 in-center hemodialysis patients who were dialyzing at this facility. Findings include: During observation in the patient treatment area on 4/21/25 between 11:16 a.m. and 1:30 p.m., the following was observed: - Five of six patients (seated at S1, S8, S9, S10, and S13) who held pressure to their needle sites, did not perform hand hygiene after glove removal and before leaving the treatment area. - The patients were not reminded by the staff to wash hands nor offered to use hand sanitizer after glove removal. According to the CDC recommendations, even with glove use, hand hygiene is necessary after glove removal because hands can become contaminated through small defects in gloves and from the outer surface of gloves during glove removal. During an interview on 4/22/25 at 3:00 p.m., the Director stated that staff know that hand hygiene must be performed after glove removal. A review of Policy 15750872 titled, “Hand Hygiene” dated 5/2024 stated the following: Hands should always be decontaminated: - Before applying and after removing gloves. - After touching blood, body fluids, secretions, excretions, and contaminated items, regardless of whether gloves are worn.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 03383 Based on observation and staff interviews, it was determined that the facility failed to ensure that five of 18 patients (P) (P#7, P#8, P#9, P#10, and #11) observed who were seated at Station (S) 2, S5, S7, S8, and S13 respectively, had their vascular access sites uncovered/visible to the staff throughout dialysis treatment, to ensure patient safety. This deficient practice could provide an opportunity for accidental needle dislodgement or a line disconnection to go undetected and could result in exsanguination (severe loss of blood). The facility census was 51. Findings include: During observation in the Patient Treatment Room on 4/21/25 between 11:17 a.m. and 12:54 p.m., the following was revealed: - P#7, P#8, P#9, P#10, and P#11’s access sites were completely covered with a blanket. The patients’ dialysis access sites were not visible during their treatment. On 4/21/25 at 11:31 a.m., Registered Nurse (RN) II, Licensed Practical Nurse (LPN) DD, LPN FF, LPN FF, LPN GG, and Patient Care Technician HH were informed about patients with covered accesses. RN II stated that they have instructed patients to keep their access uncovered but the patients complained of being cold. A review of Procedure #2015 titled, “Patient Safety Regulations” dated 7/15/2009 stated the following: Each patient, including his/her, FACE, VASCULAR ACCESS SITE, AND BLOODLINE CONNECTIONS must be able to be seen by staff member throughout the dialysis treatment. Covering the access sites and line connections provides an opportunity for accidental needle dislodgement to go undetected. This dislodgement or disconnection could result in drainage of blood and death in minutes.”