Emory Dialysis at North Decatur

“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: 32734 Based on observation, staff interviews, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of facility policy and procedures, it was determined that the Infection Control Committee failed to ensure that one of one Licensed Practical Nurse (LPN AA) observed during initiation and termination of hemodialysis (HD) treatment on one of one patient seated at Station (S)16 observed, who had Central Venous Catheter (CVC - A flexible tube that was inserted into a vein, and was guided/threaded into a large vein above the right side of the heart), utilized appropriate infection control techniques to prevent cross contamination. This breach in infection control techniques could negatively affect the health and safety of the patient seated at (S)16, and all other patients who had CVC as their dialysis access. The facility census was 112 incenter hemodialysis patient. Findings include: During observation in the Patient Treatment Room on 12/5/24 between 9:30 a.m. and 3:00 p.m., the following was observed: On 12/5/24 at 11:41 a.m., LPN AA was observed during initiation of hemodialysis treatment on a patient who had a CVC at S16. - LPN AA donned clean gloves, cleaned the CVC site starting from the inside closest to the exit site using an alcohol pad (clean to dirty) then using the same antiseptic swab proceeded to clean from the outside of the exit site back towards the clean site. - LPN AA scrubbed the hubs (plastic caps used to close the opening of the catheter lines) rubbing the hubs three time for approximately 3 seconds, then attached two three milliliter syringes to the CVC tubing and aspirated (removed) blood from each port. - LPN AA then lowered the keyboard located on the front of the machine, set the blood pump rate, flipped the dialyzer (dirty tasks)and connected the bloodlines to the CVC lines (clean task) while she wore the same gloves she had donned previously. LPN AA failed to change gloves or sanitize hands between tasks. During an interview on 12/5/24 at 11:55 a.m., LPN AA was asked if she was aware that she did not change gloves between tasks nor disinfected the CVC hubs for more than 3 seconds. LPN AA asked the surveyor, “ How many times am I supposed to scrub the hubs? “ During an exit interview on 12/5/24 at approximately 5:00 p.m., the Regional Clinic Administrator and the Clinic Nurse Manager were made aware of the above findings. 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 “Initiating, Monitoring, and Discontinuing Hemodialysis Treatments Utilizing a Central Venous Catheter using with TEGO caps in place”, Revised Date: September 2023, showed the following: Purpose: To provide safe and effective hemodialysis treatments in accordance to the Physician’s orders while using aseptic technique to substantially reduce the possibility of contamination. Practice Guidelines: Pg.3: Use an alcohol prep pad to scrub the arterial port with friction for at least 15 seconds. Be sure to scrub all areas of the hub or Tego cap to remove blood or residue. Once disinfected, attach a 3ml (milliliter) syringe to the port using aseptic technique. Repeat for venous port using a clean alcohol pad.”