Fmcna Dialysis Services Duluth Lawrenceville

“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, staff interviews, and a review of Centers for Disease Control (CDC) guidelines and facility Policy and Procedures (P & P), it was determined that the Infection Control Committee failed to ensure that two of two Patient Care Technicians (PCT AA and PCT BB) observed, did not don clean gloves after touching the patients’ equipment and performing direct patient care; or performed hand hygiene (wash hands or use an alcohol-based hand sanitizer) when going from a “dirty” area or task to a “clean” area or task. Failure to don gloves when touching contaminated surfaces and failure to perform hand hygiene increased the risk for cross contamination with the potential to expose 86 patients and all staff to bloodborne pathogens in the dialysis environment. Findings include: During observation in the treatment room on 1/7/25 at 11:44 a.m, PCT AA lowered the keyboard located on the front of the machine and set the blood pump rate (dirty tasks) then connected the bloodlines to the AVF (Arteriovenous Fistula- an access created surgically by connecting an artery and vein to be used for dialysis) to the patient’s fistula needles (clean task) while he wore contaminated gloves. PCT AA failed to change gloves or sanitize hands between dirty and clean tasks. During an interview with at 11:57 a.m., PCT AA was asked if he was aware of any breach in infection control. PCT AA stated, “I went from dirty to clean without changing my gloves”. During observations of the treatment room on 1/8/25 at 10:34 a.m., PCT BB used her fingers to hold the glove and without donning the glove, silenced the machine alarm for the patient seated at Station (S) 10. PCT BB then walked over to the patient who was seated at S12 and adjusted the blood flow rate on the machine without donning gloves or sanitizing her hands. During an interview with PCT BB at 10:45 a.m., PCT offered no response when asked if she was aware that she failed to don gloves or sanitize her hands. According to the CDC, cross contaminating (going from dirty to clean equipment/tasks/area), could cause the spread of bacteria/infections. A review of facility Policy titled, “Hand Hygiene” dated 11/06/23 version 8 showed: Purpose: To prevent transmission of pathogenic microorganisms to patients and staff through cross-contamination. Page 1: Hands will be washed with antimicrobial soap and water after contact with inanimate objects near the patient.”

“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: 32734 Based on observation, staff interviews, and a review of facility Policy and Procedures (P & P), it was determined that the facility failed to maintain a safe and sanitary environment for all staff and 86 patients who dialyzed at this facility as evidenced by unsanitary/torn equipment, furniture, and dirty floor that posed a risk in infection control. These environmental concerns were observed in one of one water treatment room, one of one storage room, and two of two patient treatment rooms. Findings include: During a tour/observation of the facility on 1/7/25 at 1:00 p.m., the following was observed: In the Water Treatment Room: - The floor drain next to the bicarbonate holding tank had visible rust colored stains. In the Storage Room: - There was visible dirt, one coffee- colored stain (approximately 8 inches long x 10 inches wide), and black scuff marks across the floor. In the Patient Treatment Room: - There were seven chase wall boxes (plastic covered boxes that are used to connect the acid and bicarbonate to the dialysis machines) with whitish colored residue buildup on them at Station (S) 2, S11, S12, S14, S16 and S17. - There were four dialysis chairs with tears in the upholstery at S3 (had a 1-inch tear in the right arm rest); chair at S7 had two 1-inch to 1½ inch tears in the headrest; chair at S 9 had a 1-inch tear in the left arm rest; and the chair at S13 had a 1-inch tear in the right arm rest. In the Isolation Room: - Paint peeling (approximately 10 inches long x 10 inches wide area) and black scuff marks on the wall behind the dialysis chair. In the Lab Area: - The handle on the left cabinet door was broken. A review of policy titled, “Infection Control Overview” dated 5/02/22 version 4 showed: Page 3 Infection Control Policies includes, but are not limited to: - Housekeeping to ensure environment is clean and sanitary. During an interview on 1/8/25 at 11:30 a.m., the Biomed Manager (BM) acknowledged the findings and stated, “Housekeeping came in last night and cleaned the Storage Room floor”. During and exit interview on 1/9/25 at approximately 3:30 p.m., the Clinical Nurse Manager and Director of Operations both acknowledged the above findings.”