Dci Fort Oglethorpe

“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 Centers for Disease Control and Prevention (CDC) recommendations, staff interview, and a review of facility Policy and Procedures (P & P), it was determined that the Infection Control Committee failed to ensure that three of three patients observed, seated at Stations (S) (S3, S10, and S11), who held pressure to their access sites for hemostasis (stopping of the flow of blood) after dialysis, performed hand hygiene after removing used gloves; one of two Licensed Practical Nurse (LPN DD), and one of one Patient Care Technician (PCT FF), observed during initiation of hemodialysis treatment, removed gloves or changed gloves when going from a “dirty” area or task to a “clean” area or task and performed hand hygiene (wash hands with soap and water or use an alcohol-based hand sanitizer) between glove changes. This deficient practice had the potential for cross contamination and increased risk of infection that could negatively affect the health and safety of all 39 hemodialysis patients who dialyzed at this facility. Findings include: During observation in the Patient Treatment Room on 6/2/25 between 11:26 a.m. and 2:48 p.m., the following was revealed: - Three patients, seated at S3, S10, and S11, were observed applying pressure to their access sites with a gloved hand for hemostasis. All three patients did not perform hand hygiene after removing their gloves and before leaving the Patient Treatment Room. The three patients were not reminded by the Direct Patient Care (DPC) staff (nurses and PCTs), to wash their hands nor offered to use a hand sanitizer after glove removal. - PCT FF was observed at 12:07 p.m., performing initiation of hemodialysis treatment tasks at S4, with gloved hands without removing gloves and without performing hand hygiene after needle insertion (cannulation). PCT FF wore the same contaminated gloves throughout the entire treatment initiation procedure, such as: touching syringes, tape and bloodlines, touching the patient’s clothing to clamp lines to, touching dialysis machine buttons (considered dirty), and touching computer keyboard (considered clean), to enter data, before gloves were removed and hand hygiene performed. - LPN DD was observed at 1:59 p.m., performing initiation of hemodialysis treatment tasks to a patient with a Central Venous Catheter (CVC) at S6. LPN DD did not perform hand hygiene when she changed gloves or between glove changes during the following tasks: when changing gloves to connect syringes to CVC ports and before clamping tubing to patient’s clothing. - LPN DD was observed at 2:48 p.m., performing initiation of hemodialysis treatment tasks to a patient with a CVC at S7. LPN DD did not perform hand hygiene when she changed gloves or between glove changes during the following tasks: when changing gloves to connect syringes to CVC ports and before clamping tubing to the patient’s clothing. According to 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. The Nurse Manager was informed about the above observations on 6/2/25 at 4:30 p.m. A review of Policy NO 306 titled, “Use of Gloves Including Hand Hygiene”, ssued on 1/16/19, stated: Hand hygiene will be performed: o After touching blood, body fluids, secretions, excretions, and potentially contaminated items o Before and after direct contact with patients o Before performing any invasive procedure such as vascular access cannulation or administration of parenteral medications o Immediately after gloves are removed o After contact with inanimate objects, including medical equipment or environmental surfaces at the patient station o Before entering·and exiting the patient treatment areas o When moving from a contaminated body site to a clean body site of the same patient”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 03383 Based on observation, staff interview, and a review of facility policy, it was determined that the Infection Control Committee failed to ensure that all Direct Patient Care Staff (nurses and Patient Care Technicians-PCTs), immediately and thoroughly cleaned and disinfected surfaces contaminated with visible dried blood on one of 15 hemodialysis chairs at Station (S)13. This deficient practice increased the risk for transmission of bloodborne pathogens and other infections from one patient to another in the hemodialysis (HD) unit and could negatively affect the health and safety of all 39 in-center hemodialysis (ICHD) patients who were dialyzing at this facility. Findings include: During a tour of the Patient Treatment Room with the Nurse Manager on 6/3/25 at 10:00 a.m., the following was revealed: - The right side of the backrest of the hemodialysis chair at S13, had a reddish-brown, dried-up drip of blood about 1 centimenter (cm) long. The facility was closed for patient treatment on this day, (Tuesday, 6/3/25), and S13 was ready for set-up on 6/4/25. This surveyor pointed this out to the Nurse Manager, who acknowledged and confirmed it after cleaning the area with a bleach rag. A review of Policy NO: 300 titled, “Routine Disinfection in the Hemodialysis Unit”, issued on 1/16/19, stated: With a new cloth/towel saturated with approved disinfectant, move to the dialysis chair. Ensure all components of the chair are cleaned top to bottom including but not limited to: - Chair - Foot rest - Head rest - Any pillows - Side tables - Remotes/call lights Pull-out foot rest Wheels - Inside arms of chairs”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 03383 Based on observation and staff interview, it was determined that the facility failed to ensure that there was a safe environment for all patients and staff, as evidenced by failure of the facility to ensure that there were no gaps or holes between the sides of the entrance/exit sliding door (Bay door that led to the outside) in the Storage Room to prevent entry of insects and vermin into the facility. The facility census was 39. Findings include: During a tour of the facility with the Nurse Manager on 6/2/25 at 10:32 a.m., the following was observed: - The entrance/exit sliding door (Bay door that led to the outside), in the Storage Room, had four round holes approximately one inch in diameter in the door’s metal tracking system located on the right side of the drawer and a 1/4 inch - 1/2 inch gap on both sides of this sliding door (Bay door), between the door and the frame/tracking system that could allow insects and vermin to enter the building. - The Nurse Manager acknowledged the above observation during the tour on 6/2/25 at 10:32 a.m., and stated that the building was old, and many changes have been made, but that it needed more work. A re-inspection of the bay door (mentioned above), on 6/3/25 at 10:00 a.m., revealed that it had not been repaired.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 03383 Based on observation and staff interview, it was determined that the facility failed to maintain a clean, orderly, and safe environment. These environmental concerns were observed in one of one Patient Treatment Room, in one of one Storage Room, in one of one Dialysate Preparation Room, in one of one Biomedical Technician’s (BMT’s) Work Room and in the corridors throughout the facility. This deficient practice could negatively affect the health and safety of all staff and 39 patients who were receiving dialysis treatment at this facility. Findings include: During a tour of the facility with the Clinical Manager on 6/2/25 at 10:32 a.m., the following was observed: In the Storage Room: - The doorframe of the entrance/exit door to/from the Storage Room was covered with a rust-colored substance and the door was ill-fitting thereby preventing full closure. - The flooring in front of the entrance/exit door was buckling and large chunks of the flooring concrete material was blackened and missing, which were approximately 12 - 14 inches in diameter. In the Patient Treatment Room, Storage Room, Dialysate Preparation Room, Corridors: - The walls in the Patient Treatment Room, Storage Room, Dialysate Preparation Room, and in the corridors throughout the facility had nicks, scrapes, bubbled paint, and holes. - All of the wooden doors throughout the facility; Nurse Practitioner’s office door, Electrical Room door, Water Treatment Area and Storage Room door, Janitorial Closet door, the office door of the Area Operations Director, and the door to the BMT’s Work Room, had nicks, scrapes, and holes. The Clinical Manager stated during the tour that the building was old, and many changes have been made, but that it needed more work. Licensed Practical Nurse (LPN DD), stated on 6/4/25 at 5:05 a.m., that the previous BMT stained the doors and didn’t know what he was doing and didn’t have the authority to make the decision to use stain on the doors, “He did a terrible job”.”

“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 interview, it was determined that the facility failed to ensure that two of 12 patients (P) (P#11 and P#12) observed in the Patient Treatment Room at Stations (S) 6 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 39. Findings include: During observation in the Patient Treatment Room on 6/2/25 between 11:26 a.m. and 2:48 p.m., the following was revealed: - P#11 had a blanket completely covering her body from neck to toe at 11:32 a.m., at S13. P#11’s dialysis access sites were not visible during treatment. Licensed Practical Nurse (LPN DD) was observed at 11:47 a.m. performing a 30-minute check (intradialytic monitoring), on P#11. LPN DD pulled back P#11’s blanket to look at her Central Venous Catheter (CVC) access, then LPN DD replaced the blanket over P#11’s access, obscuring the CVC access from visibility. - LPN DD was observed at 1:59 p.m., performing initiation of hemodialysis treatment on P#3 at S6. After LPN DD completed initiating P#3’s hemodialysis treatment, P#3 pulled her blanket up to her neck covering her access site, while LPN DD was entering data in the dialysis machine. LPN DD did not educate P#3 about the importance of keeping her access visible during treatment and did not adjust the blanket to keep the access visible to ensure patient safety. The Clinical Manager (CM) was informed about the above observation made of patients with covered accesses on 6/2/25 at 4:30 p.m. The CM stated that patients knew better than to cover their access and staff knew to uncover access. A review of undated Policy NO: 129 titled, “Routine Care of a Central Venous Catheter (CVC)”, stated: Access will remain visible throughout the entire treatment; to include catheter connection sites, blood tubing connections and dialyzer connections.”