Dci East Albany

“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 six Patient Care Techs (PCTs - PCT II, PCT FF and PCT HH), observed during initiation of dialysis 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 71 in-center hemodialysis patients who were dialyzing at this facility. Findings include: During observation in the Patient Treatment Room on 5/15/25 between 5:45 a.m. and 7:00 a.m., the following was revealed: - PCT II was observed at 5:50 a.m., performing initiation of dialysis treatment tasks at Station (S) 3 with gloved hands without removing gloves and without performing hand hygiene after needle insertion (cannulation). PCT II wore the same contaminated gloves for the entire treatment initiation, 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. - PCT II practiced the same breach in infection control techniques also during initiation of dialysis treatments to patients at S1 and S4, as described above. - PCT FF was observed at 6:11 a.m., performing initiation of dialysis treatment tasks at S11 with gloved hands without performing hand hygiene after removing gloves and before putting on a new pair of clean gloves. - PCT FF repeated the same breach in infection control techniques (not performing hand hygiene between glove changes), during initiation of treatment of patient at S10. - PCT HH was observed at 7:08 a.m., during initiation of dialysis treatment tasks at S5 with gloved hands without removing gloves and performing hand hygiene after inserting needles into patient’s dialysis access. PCT HH did not remove gloves and did not perform hand hygiene until all dialysis initiation tasks were completed. 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 5/15/25 at 2:16 p.m. A review of Procedure No: 304 titled, “Use of Gloves Including Hand Hygiene”, issued on 1/16/19 stated: 4. Gloves will be changed for the following: - When soiled (with blood, dialysate or other body fluids) - When going from a “dirty” area or task to a “clean” area or task - When moving from a contaminated body site to a clean body site of the same patient - After touching one patient or their machine and before arriving to care for another patient or touch another patient’s machine 5. A new pair of clean gloves must be used each time for the following: - Access site care - Vascular access cannulation - Administration of parenteral medications - To perform invasive procedures 6. Hand hygiene will be performed: - After touching blood, body fluids, secretions, excretions, and potentially contaminated items - Before and after direct contact with patients - Before performing any invasive procedure such as vascular access cannulation or administration of parenteral medications - Immediately after gloves are removed - After contact with inanimate objects, including medical equipment or environmental surfaces at the patient station”

“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 interviews, 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 two of 20 hemodialysis chairs at Stations (S), (S1 and S8). 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 71 in-center hemodialysis (ICHD) patients who were dialyzing at this facility. Findings include: During a tour of the Patient Treatment Room on 5/15/25 at 4:55 a.m., the following was revealed: - The under side of the right arm of the hemodialysis chair at S1, had reddish brown dried up drips of blood. This surveyor informed Patient Care Technician (PCT) HH about this discovery immediately at 4:56 a.m. This patient station (S1), had been cleaned and set-up for dialysis for the next shift. - There were brown spots of dried blood on the seat of the hemodialysis chair at S8. Registered Nurse (RN AA) was notified of this observation on 5/15/25 at 5:06 a.m. A review of Policy 1-05-01 titled, “Routine Disinfection in the Hemodialysis Unit” issued May 2023, stated: “Proper cleaning and disinfection of environmental surfaces (including patient chairs or bed surfaces, dialysis equipment surfaces, adjacent tables and work surfaces) must be performed between patient uses to prevent transmission of dangerous pathogens. With a new cloth/towel saturated with 1:100 bleach solution, move to the dialysis chair. Ensure all components of the chair are cleaned top to bottom ...””

“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 between the bottom of the exit doors and floors in one of one exit double doors in the Storage Room and one of one exit door in the Patient Treatment Room, to prevent entry of insects and vermin into the facility. The facility census was 71. Findings include: During a tour of the facility with the Nurse Manager on 5/14/25 at 11:37 a.m., the following was observed: - The double doors in the Storage Room that led to the outside had approximately 1/4 inch - 1/2 inch gap between both sides of the double doors and the floor (12 inches across the right door) that could allow insects and vermin to enter the building. - The exit door in the Patient Treatment Room that led to the outside had approximately 1/4 inch - 1/2 inch gap underneath (between the floor and the bottom of the door), that could allow insects and vermin to enter the building. - A dead roach was observed in the conference room on 5/14/25 at 11:23 a.m. The Nurse Manager was shown the dead roach on 5/16/25 at 8:30 a.m. A re-inspection of both exit doors (mentioned above), on 5/16/25 at 11:41 a.m., revealed that the gaps in both exit doors had not been repaired.”

“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: 03383 Based on observation and staff interviews, it was determined that the facility failed to ensure that one of one Bicarbonate Mixer (used to prepare the bicarbonate concentrate), was repaired and maintained at optimal function. Bicarbonate is used to help correct metabolic acidosis, a condition where the blood becomes too acidic. Kidney disease impairs the body’s ability to remove excess acid, leading to metabolic acidosis. Bicarbonate in the dialysate, acts as a base, helping to neutralize the excess acid in the blood and raise the blood’s pH, improving acid-base balance. Failure to repair and maintain the Bicarbonate Mixer could negatively affect the health and safety of all 71 in-center hemodialysis (ICHD) patients who were under the care of this facility and who relied on bicarbonate for their hemodialysis treatments. Findings include: - Patient Care Technician (PCT HH) was observed preparing bicarbonate concentrate in the Bicarbonate Mixer on 5/15/25 at 4:25 a.m. - PCT HH taped a crank handle (from a broken dialysis machine), to apply pressure to the button on the Bicarbonate Mixer panel board. PCT HH stated the button had not worked for about 1.5 years and it had been reported time and time again without being repaired. PCT HH also added that it would take a long time to complete her tasks if she had to hold the button until the bicarbonate was mixed and transferred to the Holding Tank. - The Nurse Manager (NM) was informed about the Bicarbonate Mixer issue on 5/15/25 at 8:15 a.m. The NM stated that it had not been 1.5 years, it had been more like six months. The NM stated that Mar Cor (company that provides water treatment systems for dialysis), had come and were unable to repair the button. The NM showed this surveyor, a Work Order that stated: - The Work Order was created on 7/1/2024 and was due on 7/31/24. Status: Overdue; Equipment Name: Bicarb Controls; Reported Condition: “bicarb mix button will not work, had to hold it down to mix bicarb and to transfer over”. - On 5/15/25 at approximately 8:30 a.m., the Biomed Technician (BMT) stated that they were waiting to receive a used Bicarbonate Mixer that was in good condition from another facility. The BMT provided a Mar Cor Directions For Use (DFU) for the Bicarbonate Mixer but it did not specifically address troubleshooting or maintaining flow switch.”

“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 four of 10 patients (P#10, P#11, P#12, and P#13) observed in the Patient Treatment Room at Stations (S) 5, 6, 8, and 13 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 71. Findings include: During a tour of the facility on 5/14/25 at 11:37 a.m. with the Nurse Manager, P#10, P#11, P#12, and P#13’s access sites were observed completely covered with a blanket. - P#11 had a blanket completely covering head to toe. P#11 was observed with head and access still completely covered at 1:14 p.m. The patients’ dialysis access sites were not visible during their treatment. The NM did not stop the tour to inform the Direct Patient Care staff (nurses and Patient Care Technicians) about the covered accesses, to ensure that these accesses were uncovered for patient safety. The Nurse Manager who was present during the tour, acknowledged the above observation on 5/14/25 at 11:37 a.m., but stated that these patients will not keep their accesses uncovered.”