Davita Sun Health 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: 32741 Based on document review, observation and interview, it was determined that for 1 of 1 Registered Nurse (E #2), the Facility failed to ensure that staff followed infection control practices for hand hygiene between patients, as required. Findings include: 1. On 12/19/2023, the Facility’s policy titled, “Infection Control for Dialysis Facilities” (dated April 2023) was reviewed and required, “...Hand Hygiene - all teammates, physicians and non-physicians will perform hand hygiene... between patients even if the contact is casual...” 2. On 12/18/2023, an observational tour was conducted in the dialysis treatment area between 8:45 AM and 11:00 AM. The following was observed: -At approximately 10:00 AM, E #2 was providing patient care at Station #15 and then went to Station #16 and provided patient care without performing hand hygiene. -At approximately 10:35 AM, E #2 was providing patient care at Station #15 and then went to Station #16 and provided patient care without performing hand hygiene. 3. On 12/18/2023 at 11:15 AM, an interview was conducted with E #2. E #2 stated that hand hygiene is performed between patient contact.”

“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 2 of 3 Patient Care Technicians (E #3 & E #4) and 1 of 1 Registered Nurse (E #2) observed cleaning and disinfecting dialysis stations, the Facility failed to clean/disinfect all areas of the dialysis station, as required. Findings Include: 1. On 12/19/2023, the Facility’s policy titled, “Infection Control for Dialysis Patients” (dated April 2023) was reviewed and required, “...At the end of the treatment, the dialysis station will be cleaned and disinfected...Surfaces to disinfect include but are not necessarily limited to - all surfaces in contact with the patient or their belongings...” 2. On 12/18/2023 between 8:45 AM and 11:00 AM, an observational tour was conducted in the dialysis treatment area and the following was observed: -At approximately 9:30 AM, the Patient Care Technician (E #3) was cleaning the dialysis station #8 and failed to clean/disinfect the TV monitor. -At approximately 10:00 AM, the Registered Nurse (E #2) was cleaning the dialysis station #14 and failed to clean/disinfect the TV monitor. -At approximately 10:10 AM, the Patient Care Technician (E #4) was cleaning the dialysis station #12 and failed to clean/disinfest the TV monitor. 3. On 12/18/2023 at approximately 11:20 AM, an interview was conducted with the E#4. E #4 stated that all areas of the dialysis station should be cleaned and disinfected, including the TV monitor.”

“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 1 of 1 Registered Nurse (E #2) and 1 of 1 Patient Care Technician (E #3) 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 12/18/2023, the Facility’s policy titled, “AV Fistula or Graft Cannulation with JMS Sysloc Mini Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose” (dated October 2022) was reviewed and required, “...Isopropyl Alcohol 70% - at least 4 prep pads per site - effective contact time 60 seconds...” 2. An observational tour of the dialysis treatment area was conducted on 12/18/2023, between approximately 8:45AM and 11:00 AM. The following was observed: - At approximately 9:50 AM, a Registered Nurse (E #2) was at station #15, 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 60 seconds), then inserted the catheter needle. E#5 then wiped the second access site with alcohol for a total of 10 seconds (not the required 60 seconds), then inserted the catheter needle. -At approximately 10:20 AM, a PCT (E#3) was at station #6, preparing to initiate dialysis for a patient with an AVF. E #5 wiped the first access site with alcohol for a total of 20 seconds (not the required 60 seconds), then inserted the catheter needle. E #5 then wiped the second access site with alcohol for a total of 20 seconds (not the required 60 seconds), then inserted the catheter needle. 3. On 12/18/2023 at 11:15 AM, an interview was conducted with the Registered Nurse (E #2). E #2 stated that for AVF cannulation, each site should be disinfected for 5 seconds.”