Fmc - South Chicago

“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: 32741 Based on document review, observation and interview, it was determined that for 3 of 4 Patient Care Technicians (E #2, E #3 and E#5) observed cleaning and disinfecting dialysis stations, the Facility failed to follow infection control precautions by not cleaning/disinfecting equipment, as required. Findings Include: 1. On 1/9/2024, the Facility’s policy titled, “Cleaning and Disinfecting Dialysis Surfaces & Equipment” (dated 9/5/2023) was reviewed and required, “...Follow the steps below to disinfect the dialysis station after each dialysis treatment - clean and disinfect the dialysis station (IV pole, BP cuff...) - Open side panels if chairs has swing open sides so all surfaces of the chair are accessible...” 2. On 1/9/2024 between 8:45 AM and 11:15 AM, an observational tour was conducted in the dialysis treatment area. The following was observed: - At approximately 9:15 AM, the Patient Care Technician (E #2) was cleaning the dialysis station #11. E #2 did not fully open the side panels on the dialysis chair for cleaning/disinfecting. -At approximately 9:40 AM, the Patient Care Technician (E #3) was cleaning the dialysis station . #14. E #3 did not fully open the side panels on the dialysis chair for cleaning/disinfecting. -At approximately 9:45 AM, the Patient Care Technician (E #5) was cleaning the dialysis station #31. E #5 did not clean or disinfect the TV and did not fully open the side panels on the dialysis chair for cleaning/disinfecting. 3. On 1/9/2024 at approximately 11:15 AM, an interview was conducted with the E#5. E #5 stated that all areas of the dialysis station including the TV should be cleaned/disinfected. E #5 stated that the sides of the chairs should be opened fully when cleaning/disinfecting dialysis chair.”

“IC-TRAINING & EDUCATION CFR(s): 494.30(a)(1)(i) Infection Control Training and Education Infection control practices for hemodialysis units: intensive efforts must be made to educate new staff members and reeducate existing staff members regarding these practices. This Standard is not met as evidenced by: 32741 Based on document review, observation, and interview, it was determined that for 3 of 4 Patient Care Technicians - PCT (E #2, E #6 and E #7) observed for disinfecting AVF (arteriovenous fistula) cannulation sites, the Facility failed to ensure that staff followed infection control practices to disinfect and prevent contamination of AVF sites, as required. Findings include: 1. On 1/9/2024, the Facility’s procedure titled, “Access Assessment and Cannulation” (dated 7/5/2022) was reviewed and required, “Skin disinfection - 70% isopropyl alcohol pad: Use gentle friction, clean the access site beginning in the center and continuing outward 2 inches in a concentric circle for 30 seconds and allow to dry before cannulation...” 2. An observational tour of the dialysis treatment area was conducted on 1/9/2024, between approximately 8:45 AM and 11:15 AM. The following was observed: - At approximately 9:25 AM, a PCT (E #7) was at station #22, preparing to initiate dialysis for a patient with an AVF. E#5 wiped the first access site with alcohol for a total of 5 seconds (not the required 30 seconds), then immediately inserted the catheter needle. E #7 then wiped the second access site with alcohol for a total of 5 seconds (not the required 30 seconds), then immediately inserted the catheter needle. -At approximately 10:05AM, a PCT (E#6) was at station #36, preparing to initiate dialysis for a patient with an AVF. E #4 wiped the first access site with alcohol for a total of 10 seconds (not the required 30 seconds), then immediately inserted the catheter needle. E #4 then wiped the second access site with alcohol for a total of 10 seconds (not the required 30 seconds), then immediately inserted the catheter needle. -At approximately 10:20 AM, a PCT (E #2) was at station #11, preparing to initiate dialysis for a patient with an AVF. E #2 wiped the first access site with alcohol for a total of 10 seconds (not the required 30 seconds), then immediately inserted the catheter needle. E #2 then wiped the second access site with alcohol for a total of 10 seconds (not the required 30 seconds), then immediately inserted the catheter needle. 3. During an interview on 1/9/2024 at 11:10 AM, E #2 stated that each site for AVF site should be disinfected for 30 seconds prior to cannulation.”

“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: 32741 Based on document review, observation and interview, it was determined that for 2 of 4 Patient Care Technicians - PCT ( E #3 and E #6 ), the Facility failed to ensure that staff demonstrated knowledge of the Facility’s infection control practices for the disinfection of CVC (central venous catheter - used for dialysis access) insertion site for initiation of the dialysis treatment, as required. Findings include: 1. On 1/9/2024, the Facility’s policy titled, “Changing the Catheter Dressing Procedure” (dated 5/2/2022) was reviewed and required, “...Cleaning the Site - Follow the steps below to clean the catheter exit site - 70% alcohol -Use gentle friction, disinfect the access site beginning in the center and continuing outward 2 inches in a concentric circle for 30 seconds and allow to dry...” 2. On 1/9/2024 between 8:45 AM to 11:15 AM, an observational tour of the dialysis treatment area was conducted. The following was observed: - At approximately 10:15 AM, a Patient Care Technician (E #3) was observed disinfecting a CVC site at station #20. E #3 disinfected the CVC site with 70 % alcohol for 20 seconds instead of 30 seconds, as required. -At approximately 10:25 AM, a Patient Care Technician (E #6) was observed disinfecting a CVC site at station #35. E #6. E #6 disinfected the CVC site with 70% alcohol for 15 seconds instead of 30 seconds, as required. 3. On 1/9/2024 at 11:00 AM, an interview was conducted with E #3. E #3 stated that the CVC site should be disinfected for 1 minute using a circle motion.”