Fmc - North Gwinnett 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: 33921 Based on observation, staff interviews, a review of facility Policy and Procedures (P& P), and Centers for Disease Control and Prevention (CDC) Recommendations, it was determined that the Infection Control Committee failed to ensure that three of three Patient Care Technicians (PCT CC, PCT BB, PCT AA), one of one Registered Nurse (RN AA) and three of three patients (P#1, P#2, and P#3) observed, performed hand hygiene (washed hands or used an alcohol-based hand sanitizer), after removal of contaminated gloves, between glove changes and after touching contaminated equipment. Failure to perform infection control techniques such as hand hygiene, increased the risk for cross contamination with the potential to expose patients and staff to blood-borne pathogens in the dialysis environment. This deficient practice had the potential to negatively affect 57 in-center hemodialysis patients who dialyzed at this facility. Findings include: 1. During observation in the Patient Treatment Room on 2/7/24 between 10:30 a.m. and 12:00 p.m., the following was revealed: - PCT CC was observed entering information on the hemodialysis screen for patient at Station (S) 10. PCT CC then went to S8 (considered dirty) to reset the machine alarm, without changing gloves and without performing hand hygiene. PCT CC then changed gloves without performing hand hygiene between glove changes, and went to S11 to reset the machine (considered dirty) alarm. PCT CC removed her glove from her right hand, again did not perform hand hygiene, then touched the computer keys (considered clean). - This observation was brought to the attention of PCT CC on 2/7/24 at 10:50 a.m. PCT CC acknowledged this observation with a nod but did not make a comment. - A review of the facility’s Policy #1-05-01 titled, “Infection Control for Dialysis Facilities” with latest revision date of April 2023, stated: Hand Hygiene: 1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene: b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact... g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse 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 ... 49321 2. During observation in the Patient Treatment Room on 2/9/24 from 9:00 a.m. to 10:00 a.m., the following was revealed: - Patient (P) #1 who was seated at S10, was observed applying pressure to his dialysis access site, with a gloved hand. When hemostasis (stopping of the flow of blood) was achieved, P#1 removed his glove and did not perform hand hygiene. - PCT AA did not remind P#1 to perform hand hygiene after glove removal. - PCT AA applied gauze dressing over P#1’s access site, removed her gloves, performed hand hygiene and put on a clean pair of gloves. PCT AA then gathered contaminated blue pad, placed it in the trash, touched/moved the hemodialysis machine, then escorted P#1 to the lobby. - PCT AA touched the scale, the thermometer, and the doorknob that led to the lobby while she wore contaminated gloves. During the interview with PCT AA on 2/9/24 at 9:15 a.m., she stated that she usually offers her patients hand sanitizer. - P#2, who was seated at S17 was observed applying pressure to his dialysis access site, with a gloved hand. When hemostasis was achieved, P#2 removed his glove and did not perform hand hygiene before RN AA escorted him to the lobby. - RN AA touched thermometer, scale, and doorknob while she wore contaminated gloves that she used when she touched the dialysis machine and treatment chair at S17. - RN AA did not remind P#2 to wash his hands or use a hand sanitizer after glove removal and prior to leaving the facility. During an interview on 2/9/24 at 9:35 p.m., RN AA stated she did not realize that she touched the machine and the dialysis chair at S17. - P#3 who was seated at S20, was observed applying pressure to his dialysis access site, with a gloved hand. When hemostasis was attained, P#3 removed his glove and did not perform hand hygiene. - PCT BB did not remind P#3 to wash his hands or use a hand sanitizer before she escorted him to the lobby. - PCT BB touched the scale, a writing pen at the desk, and doorknob while she wore contaminated gloves. During an interview on 2/9/24 at 9:45 a.m., PCT BB stated that she forgot to remind P#3 to wash his hands prior to leaving the facility.”

“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: 33921 Based on observation and staff interview, it was determined that the facility failed to ensure that one of one handwashing sink in one of one Peritoneal Dialysis (PD) Home Training and Support Room had warm running water for hand washing to encourage patients and staff to wash their hands. This deficient practice had the potential to negatively affect the health and safety of one of one Patient (P#8)who was undergoing PD Training, and all 20 PD patients who were under the care of this facility and two of two Direct PD Patient Care Staff, (Registered Nurses: RN CC and RN DD). Findings include: - During observation of P#8’s PD training in the facility’s one of one PD Home Training Room on 2/7/24 between 9:50 a.m. and 10:15 a.m., one of one handwashing sink for both staff and patients, did not have warm running water. The water in this sink did not warm up after running for more than two minutes. RN CC acknowledged and stated on 2/7/24 at 10:00 a.m., that there had been no warm running water in the handwashing sink for sometime.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 49321 Based on observations, staff interviews, and a review of the Centers for Disease Control and Prevention (CDC) Recommendations, it was determined that the Infection Control Committee failed to ensure that two of two Registered Nurses (RN AA and RN BB) and two of three Patient Care Technicians (PCT AA and PCT BB) observed, utilized appropriate infection control techniques to prevent cross contamination. This failure could lead to the transmission of dangerous pathogens through cross contamination. The facility census was 57. Findings were: During observations in the Patient Treatment Room on 2/7/24 and on 2/9/24 between 9:00 a.m. to 11:15 a.m., the following was revealed: - RN BB was was observed during initiation of P#2’s dialysis treatment at Station 4. - RN BB flushed the arterial and venous ports of Pt #2’s CVC (a large plastic tube placed in a vein in the neck or groin for exchange of blood to and from the hemodialysis machine during the hemodialysis treatment) access. - RN BB took his gloves off and did not perform hand hygiene prior to obtaining two clamps from a container of clean clamps. During an an interview on 2/7/24 at 11:25 a.m., RN BB confirmed the above finding. - PCT AA, RN AA, and PCT BB were observed discontinuing dialysis treatment (dirty task) on Patient (P) #1, P#2, and P#3 respectively. - When finished, PCT AA, RN AA, and PCT BB escorted P#1, P#2, and P#3 to the Lobby (clean area) while they wore gowns and contaminated gloves that were used during discontinuation of dialysis treatments. During interviews on 2/9/24 at 9:35 a.m., RN AA stated no one ever said anything about us wearing our gowns and gloves in the Lobby; and on 2/9/24 at 9:45 a.m., PCT BB stated “I forgot”. A review of the CDC’s Donning and Doffing (putting on and taking off) PPE, under Proper Wearing, Removal, and Disposal stated: PPE should be removed before entering any non-clinical areas including restroom, breakroom and administrative areas.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 49321 Based on observation, staff interview, a review of facility policy and National Kidney Foundation Kidney Disease Outcome Quality Initiative (NKF KDOQI) Vascular Access Guideline, it was determined that the Infection Control Committee failed to ensure that one of one Registered Nurse (RN BB) observed during initiation of hemodialysis (HD) treatment through a Central Venous Catheter (CVC - a large plastic tube placed in a vein in the neck or groin for exchange of blood to and from the hemodialysis machine during the hemodialysis treatment) access, utilized appropriate infection control techniques to prevent cross contamination. This breach in infection control techniques could negatively affect the health and safety of all patients who had CVC, as their dialysis access. The in-center HD census was 57. During observation in the Patient Treatment Room on 2/7/24 between 10:30 a.m. and 11:15 a.m., the following was revealed: - RN BB was observed during initiation of HD treatment on P#1, who had a CVC at Station (S) 3. P#1’s mask did not cover his nose during the entire procedure as well as during the CVC dressing change.. During an interview on 2/7/24 at 11:20 a.m., RN BB stated “I was not aware his mask was not pulled over his nose”. A review of Policy: 47265 titled, “Initiation and Termination of Treatment Using a Central Venous Catheter (CVC)” stated: A mask must be worn that covers the nose and the mouth by staff, patient, and caregiver for all procedures that require accessing the catheter. A review of the NKF KDOQI Vascular Access Guideline (2006) stated: Airborne contaminants from both patients and staff are prevented best by the use of surgical masks when the catheter lumens or exit site are exposed.”

“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: 33921 Based on observations and staff interviews, it was determined that the facility failed to ensure that a call light was accessible to one of one patient (P#8), who was currently undergoing PD Training; and the building in which dialysis services were provided, was maintained free from damages and defects to ensure the safety of all 57 in-center hemodialysis (ICHD) patients and seven of seven in-center Direct Patient Care Staff (Registered Nurses - RN AA and RN BB and Patient Care Technicians- PCTS AA, BB and CC), and two of two Peritoneal Dialysis (PD) Staff, (RN CC and RN DD) who were present during this observation. The total number of Direct Patient Care Staff (RNs and PCTs), was 14. This environmental concern was observed in one of one Peritoneal Dialysis (PD) Home Training and Support Room, one of one Patient Treatment Room, one of one Water Treatment Room, and one of one Biomed/Supply Room. Findings include: During observation on 2/7/24 between 9:50 a.m. and 12:00 p.m., the following was revealed: In the PD Home Training and Support Room: - The left drawer handle was broken. The left drawer was for clean supplies. RN DD stated on 2/7/24 at approximately 10:10 a.m., that yes the drawer handle was broken and had been broken for sometime. - The call light was located in the opposite wall, approximately 10 - 12 feet away from where P#8’s dialysis chair was located. If P#8 needed assistance or had an emergency situation, P#8 and the other 20 PD patients, who were under the care of this facility and who will be using this room will not be able to reach the call light. RN CC stated on 2/7/24 at 9:55 a.m., that they had moved the dialysis chair in the opposite wall for better space but didn’t take into consideration the call light’s location. In the In-Center Patient Treatment Room: - There was standing water on the floor around the hemodialysis machine #7 at Station (S) 1. RN AA stated on 2/7/24 at approximately 12:00 p.m., that the Heat Module of the machine was broken and the Biomed Technician (BMT) was supposed to have ordered it. - There was an approximately 12 inches in circumference and diameter of a water mark on the ceiling tile above S12. 49321 - The drains to the sinks across S5 and S7 leaked water on the floor. There were puddles of water under the drains. - The left wall in the Laboratory Station was chipped and covered with skid marks from the middle of the wall to the floor. - The linoleum seams at S17 was separated and the floor under the linoleum was damp. - The baseboard at S17 was separated from the wall and damp. During a tour of the Water Treatment Room and Biomed/Supply Room on 2/6/24 between 2:00 p.m. and 3:30 p.m., the following was observed: - There was a light coming in under the double back doors that could allow insects, rodents, and water to enter the facility. During an interview on 2/6/24 at 2:15 p.m., the BMT stated that the company put a drain outside the back door because the Supply Room would be flooded if it rains. Stated he will put in a ticket for repair. - The baseboards throughout the Water Treatment Room was in general disrepair. For example: The baseboard behind the water heaters was water damaged as evidenced by brown discoloration and stains on the baseboard. The baseboard next to the right door all the way around and behind the second carbon tank was moist. There was approximately two feet of baseboard under the treated water sample ports that was saturated with water and was covered with brown stain/substance. - There was approximately seven to eight inches in circumference and diameter of a brown circular stains on the ceiling tile above the small water heater. The BMT stated on 2/6/24 at 2:30 p.m., that he will put in a ticket for the ceiling tiles and for the area behind the hot water heaters. - The floor in the Biomed Area had approximately two and a half feet of cracked and chipped paint. - The floor in the Supply Room had cracked concrete approximately three and a half feet in lenght and four one inch holes. On 2/6/24 at 2:40 p.m., the BMT stated the floor was under warranty and a repair ticket has been submitted for the crack. The failure to maintain the integrity of all surfaces, could hinder effective cleaning and disinfection of surfaces and could promote microbial growth.”