Davita Woodridge Home Dialysis Pd

“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: 40079 Based on document review, observation, and interview, it was determined that for 1 of 2 staff (E#5) observed for hand hygiene, the Facility failed to ensure that staff changed gloves and/or performed hand hygiene as required. Findings include: 1. The Facility’s policy titled, “Infection Control for Dialysis Facilities” (revised April 2024), was reviewed and required, “All teammates... 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...” 2. During a tour of the dialysis treatment area on 12/30/2024 at approximately 8:26 AM, a Patient Care Technician/PCT (E#5) was initiating dialysis for a patient (Pt.#6) at station #1. E #5 was observed working on the dialysis machine ’ s computer screen with gloved hands, while holding the dialysis lines. E #5 then turned to (Pt.#6) and connected the lines to the Central Venous Catheter ports, E #5 did not change gloves and perform hand hygiene prior. 3. An interview was conducted with the Manager of Clinical Services (E #4) on 12/30/2024, at approximately 9:18 AM. E #4 stated that all staff must perform hand hygiene after touching the dialysis screens or inanimate objects and before accessing any vascular access or performing a new task.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 40079 Based on observation, interview, and document review, it was determined that for 1 of 1 (E #3) Registered Nurse observed, the Facility failed to ensure staff compliance with aseptic technique when during medication preparation of intravenous medications. This potentially affects 9 patients on the schedule on 12/30/2024. Findings include: 1. On 12/30/2024 at approximately 08:50 AM, the Nurse (E# 3) was observed preparing multiple syringes with heparin (blood thinner) from a previously opened vial. E #3 inserted an empty syringe with needle into the vial of heparin and withdrew the medication and placed a cap on the syringe. E #3 then continued to prepare an additional five syringes from the same vial syringes. E #3 did not wipe the rubber stopper each time prior to withdrawing the medication. 2. The Facility’s policy titled, “DSD (Davita Skilled Nursing Facility Dialysis) Medication Policy” (revised 04/2021) was reviewed and required, “...8. All teammates administering medications must ulitize aseptic technique. ... 14. Use aseptic technique for disinfection of vials prior to entry when preparing...” 3. An interview was conducted with the Manager of Clinical Services (E #4) on 12/30/2024 at approximately 9:10 AM. E #4 stated that when preparing medications from a multi-use vial, the rubber stopper must be disinfected prior to inserting a new syringe to prevent cross contamination.”

“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: 40079 Based on observation, document review, and interview, it was determined that for 1 of 2 staff (E#5) observed initiating dialysis treatment with central venous catheter (CVC), the facility failed to ensure that the patient wore a mask that covered their nose. Findings include: 1. During a tour of the dialysis treatment area at L#2 on 12/30/2024, at approximately 8:23 AM, Patient Care Technician/PCT (E #5) was initiating dialysis treatment for a patient with a CVC. E#5 did not ensure that the patient’s mask was covering patient’s nose when the catheters were opened and during site care. 2. The facility’s policy titled, “Central Venous Catheter (CVC)” (revised 10/2024), was reviewed and required, “...Procedure: Teammate and patient will wear masks covering the nose and mouth during procedure... These measures are vital to preventing the exposure of the catheter and exit site to nasal droplets and infectious bacteria ...”” 3. An interview with the Manager of Clinical Services (E #4) was conducted on 12/30/2024, at approximately 9:15 AM. E #4 stated that when accessing a CVC, the staff and patient should be wearing a mask that covers the nose and mouth to prevent possible contamination of the catheter.”