Davita Jesse Jewell 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, patient and staff interviews, a review of facility Policy and Procedures (P& P), facility records, and Centers for Disease Control and Prevention (CDC) Recommendations, it was determined that the Infection Control Committee failed to ensure that two of two patients (P), (P#6 and P#7) observed, performed hand hygiene (washed hands or used an alcohol-based hand sanitizer), after removal of contaminated gloves, and before leaving the Patient Treatment Room. Failure to perform hand hygiene, increased the risk for cross contamination with the potential to expose other patients and staff to bloodborne pathogens in the dialysis environment. The facility in-center census was ___. Findings were: During observation in the Patient Treatment Room on 10/8/24 between 10:15 a.m. and 11:45 a.m., the following was revealed: - P#6 at Station (S4) did not perform hand hygiene after holding his access site at the end of his treatment and before leaving the Patient Treatment Room. Patient Care Technician (PCT BB), who assisted P#6 to the weighing scale, did not remind P#6 to perform hand hygiene after removing his contaminated glove and before leaving the Patient Treatment Room. - P#7 at S7 held his access site without wearing a glove. This observation was brought to PCT AA’s attention on 10/8/24 at 10:08 a.m., and he stated, “Oh, okay”. PCT AA assisted P#7 to put on a glove (on P#7’s right hand), without offering P#7 a hand sanitizer nor encouraging P#7 to wash his hands before putting on his glove. After holding his access site, P#7 left the Patient Treatment Room without performing hand hygiene and was not reminded by PCT AA. - P#8, P#9, and P#10, stated on 10/8/24 between 11:35 a.m. and 11:45 a.m., that they were told to wash their hands before and after treatment but sometimes forgot. - 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: 2. Patients and caregivers will be encouraged to a. Wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis. b. Perform hand hygiene after treatment before leaving treatment area. - There was no documentary evidence that P#6 and P#7 received education regarding Hand Hygiene. 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 ...”

“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: 33921 Based on observation, staff interviews, a review of Centers for Disease Control and Prevention (CDC) guidelines, and a review of the facility’s policies and procedures (P & P), it was determined that the Infection Control Committee failed to ensure that all Direct Patient Care (DPC) Staff, (Registered Nurse - RN BB, and Patient Care Technicians - PCTs AA and BB), who were present during this observation, immediately and thoroughly cleaned and disinfected blood-contaminated surfaces on the covers of four of six sharps containers observed, between patient use; and to ensure that one of one Patient Care Technician (PCT AA) observed, utilized appropriate infection control techniques to prevent cross contamination. This failure could lead to the transmission of dangerous pathogens through cross contamination; and had the potential to negatively affect the health and safety of nine of nine patients (P), (P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14), who were undergoing hemodialysis treatment at the time of this observation. The facility census was 47. Findings were: During observation in the Patient Treatment Room on 10/8/24 between 10:15 a.m. and 11:45 a.m., the following was observed: - The covers of Sharps Containers located at Stations (S1, and S6), next to the laboratory area, and next to the dirty sink , had spattered droplets of dried blood on the top covers of the Sharps Containers. RN BB was notified of this observation on 10/8/24 at approximately 10:50 a.m., which she acknowledged. - PCT AA transferred the TV (television) remote control from S1 to S5 without first disinfecting the surface of the TV control for patient, (P#6) at S5 to use. - When this breach in infection control practice was brought to PCT AA’s attention on 10/8/24 at approximately 11:00 a.m., he stated, “Oh, okay”. According to CDC guidelines, failure in environmental cleaning and disinfection have led to transmission of bloodborne pathogens (e.g., Hepatitis B virus) and other infections from one patient to another in hemodialysis units. Correct cleaning and disinfection of environmental surfaces (including floors, patient chair or bed surfaces, dialysis equipment surfaces, adjacent tables and work surfaces, etc., especially with blood splatters) must be performed between patient uses to prevent transmission of dangerous pathogens. A review of facility Policy: 1-05-01, titled, “Infection Control for Dialysis Facilities” with latest revision date of April 2023, stated: 12. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials... ... iii. Cleaning of visible blood should be performed when first observed... 14. Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station...”

“PQ-H20 TREATMENT SYSTEM TECHS TRAINING CFR(s): 494.140(f) Technicians who perform monitoring and testing of the water treatment system must complete a training program that has been approved by the medical director and the governing body. This Standard is not met as evidenced by: 33921 Based on a review of personnel records and staff interview, it was determined that the facility failed to ensure that one of one Patient Care Technician (PCT DD), who was responsible for the operation of the water/dialysate system equipment and new to dialysis, completed a training program that was accurate and that was approved by the Medical Director and the Governing Body. Findings were: A review of PCT DD’s personnel records revealed the following: - PCT DD was hired on 3/25/24, with no prior PCT experience. - A review of PCT DD’s training of the facility’s CEC 4012 ICHD (In-center Hemodialysis, sic) Multi-Station Basic Components & Monitoring of Dialysis Quality Water Treatment Systems (Procedural Skills Verification Checklist for Teammates Who Perform Water Monitoring & Testing), showed that each of the procedural skills checklist was dated 1/10/24 with the initials of the PCT Preceptor (PCT PP) under the column, “Demonstration of skills by teammate. Date and Preceptor Initial”. Under the column, “Satisfactory Performance of skill by teammate. Date and Initial of RN or Biomed Trainer”, each skill was also dated 1/10/24 and initialed by the Registered Nurse Trainer (RN AA). This document was also signed by PCT DD with the same date, 1/10/24. There was no signature of approval by the Medical Director. - A review of PCT DD’s training for “PCT Procedural Skills Verification Checklist” showed that PCT DD’s initiation of the skills checklist started on 3/25/24 and ended on 5/13/24. However, the “PCT Procedural Skills Verification Checklist Completion”, was dated 4/30/24 and signed by PCT DD, RN Trainer (RN AA), and by the Facility Administrator. There was no signature of approval by the Medical Director. - The Facility Administrator acknowledged and confirmed this discrepancy when notified by this surveyor on 10/9/24 at approximately 11:00 a.m.”