Usrc Macon Clinton 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: 32734 Based on observation and staff interview, it was determined that the facility failed to ensure that one of one Patient Care Technician (PCT AA) observed, changed gloves when going from a “dirty” area or task to a “clean” area or task. This failure increased the risk for cross contamination with the potential to expose all staff and 79 in-center hemodialysis patients who dialyzed at this facility, to bloodborne pathogens in the dialysis environment. Findings were: During observation in the Patient Treatment Room on 5/22/24 between 1:15 p.m. and 2:30 p.m., the following was revealed: At approximately 1:21 p.m., PCT AA was observed during termination of P#1’s dialysis treatment. PCT AA touched/pushed the foot rest of the dialysis chair down and moved the television set to the back of P#1’s chair (dirty tasks), touched the keyboard (clean area/task), moved the patient’s walker (dirty task), then proceeded to reinfuse/return P#1’s blood and disconnected the bloodlines from the dialysis needles (clean task) while he wore the same/contaminated pair of gloves. During an interview on 5/22/24 at 2:10 p.m., PCT AA acknowledged that he failed to change gloves when going from a “dirty” area or task to a “clean” area or task.”

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 49321 Based on observation and staff interview, it was determined that the facility failed to ensure that three of four handwashing sinks in one of one Patient Treatment Room had warm water for hand washing, to encourage patients and staff to wash thier hands. This deficient pratice had the potential to negatively affect the health and safety of ten of ten patients (P# 9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17, P#18), who were undergoing hemodialysis treatment at the time of this observation and six of six Direct Patient Care staff (Charge Nurse AA, Registered Nurse AA, Patient Care Technicians AA, BB, CC, and DD). The facility census was 79. Findings include: During observation in the Patient Treatment Room on 5/22/24 at 12:41 p.m., it was revealed that three of four handwashing sinks did not have warm running water from the faucets. The Biomed Technician confirmed the above findings on 5/22/24 at 1:15 p.m., and stated that he put a ticket in for this, two weeks ago.”

“MICROB MONITOR-MO DIALYS SAMPLE/COLLECT/FREQ CFR(s): 494.40(a) 7.2 Microbial monitoring methods: 7.2.1 General: Dialysate: monthly dialysate sample/collection/freq Culture ...dialysate fluid weekly for new systems until a pattern has been established. For established systems, culture monthly unless a greater frequency is dictated by historical data at a given institution. Dialysate samples should be collected from at least two machines monthly and from enough machines so that each machine is tested at least once per year. If testing of any dialysis machine reveals a level of contamination above the action level, an investigation should be conducted that includes retesting the offending machine, reviewing compliance with disinfection and sampling procedures, and evaluating microbiological data for the previous 3 months to look for trends. The medical director also should be notified. An example of a decision tree for this process is given in Figure 1. 7.2.2 Sample collection Dialysate samples should be collected from a dialysate port of the dialyzer ... [or] dialysate sampling ports that can be accessed using a syringe. At least 25 mL of fluid, or the volume specified by the laboratory performing the test, should be collected in sterile endotoxin-free specimen containers. This Standard is not met as evidenced by: 49321 Based on a review of facility records and staff interview, it was determined that the facility failed to ensure that the dialysate (dialysis solution) samples were collected for microbial monitoring from three of 24 dialysis machines (#16, #17, and #18) at least once per year. This failure had the potential to negatively affect 79 incenter- hemodialysis patients who dialyzed at this facility. Findings were: A review of Water/Dialysate Cultures and Endotoxin Log revealed the following: - Machines #16, #17, and #18 last documented cultures was done in March 2023. A review of Policy: TM 05-01 titiled “Microbiology - Water and Dialysate” dated 04/2023 showed the following: 1. The Facility Administrator or designee (Biomed Technician) is responsible for ensuring that cultures and endotoxin are obtained, results are recorded, reviewed and necessary actions are taken as applicable. 2. The Medical Director, Facility Administrator and Biomed Technician must review all water cultures and endotoxin results monthly and sign the monthly summary report printed from the labs. 5. Monthly sample sites include: 10% of all dialysis machines or a minimun of two machines per month (all dialysis machines must be cultured at least annually (yearly). During an interview on 5/24/24 at 9:00 a.m., the Biomed Manager stated that machines #16, #17, and #18 were not cultured on their annual due date which was March 2024.”