Davita Adams County Dialysis

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 50688 Based on observation, document review, and interview, it was determined the facility failed to ensure infection prevention and control measures were followed to prevent the potential for cross contamination. Findings include: 1. On 10/02/24 at approximately 2:00 PM, an observational tour was conducted of the treatment area. It was noted that 1 of 19 dialysis treatment chairs vinyl was torn with the foam exposed on the chair seat. 2. On 10/3/24, the policy titled “Infection Control for Dialysis Facilities” (Policy 1-05-01, revised April 2023), was reviewed. The policy states, “11. Measures will be taken to prevent cross contamination between patients.” 3. On 10/3/2024 at approximately 9:45 AM, an interview was conducted with the Facility Administrator (E #1). E #1 noted she was aware of a tear in a chair and had previously informed BioMedical personnel, and a replacement was ordered. Documentation of this was requested. E #1 subsequently informed at 11:30 AM, that documentation of the replacement request could not be located.”

“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: 50688 Based on document review, observation, and interview, it was determined the Facility failed to ensure proper hand hygiene measures to prevent contaminant transmission for 3 of 6 Patient Care Technicians (PCT) and 1 of 4 Registered Nurses (RN). Findings include: 1. On 10/3/2024 the policy titled “Infection Control for Dialysis Facilities” (Policy 1-05-01), was reviewed, and requires, “All teammates, Physicians and Non-Physician (NPP) 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, e. after interacting with wall boxes (i.e., plugging/unplugging acid/bicarbonate lines from dialysis machine, changing acid types, when exchanging a dialysis machine) ...f. between patients even if the contact is casual, ...g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. 2. During observation of the patient treatment floor on 10/1/2024 from 12:25 PM until 1:45 PM, the following was observed: a. At 12:45 PM E#2 (PCT) was observed touching a machine at station #10 and then moved to station #9 to disconnect the lines from a patient’s fistula without performing hand hygiene before applying new gloves. b. At 1:00 PM, E#2 was observed touching their hair and other surfaces and picked up trash off the floor with bare hands. E#2 then cleaned the chair at station #9 with gloved hands before performing hand hygiene and then began to set up another chair with supplies without performing hand hygiene before applying new gloves. c. At 12:50 PM, E#3 (PCT) was observed disconnecting a patient from station #10, removed their gloves, applied new gloves then cleaned the chair for station #10 without performing hand hygiene before applying new gloves. E#3 did not perform hand hygiene after cleaning station #10 then moved to station #18 and touched the computer and machine with bare hands. d. At approximately 12:45 PM, E#4 (RN) was observed performing hand hygiene and applying gloves, walking to patient station #16 holding medication and stating “I forgot a mask” while touching face with gloved hand, walking to get a mask and applying it to face, returning to the patient station and administer medication to CVC without performing hand hygiene and applying new gloves. 3. During observation on the patient treatment floor on 10/2/2024 from 12:00 PM to 2:45 PM, the following was observed: a. At 12:15 PM, E#2 was observed cleaning the chair at station #18. E#2 removed their gloves, then acquired new supplies for another patient and set up station #18 without first performing hand hygiene before changing gloves. b. At approximately 1:15 PM, E#5 (PCT) was observed applying mask, looping behind ears, with gloved hands, then touching glasses with gloved fingers, then detaching the line from the patient at station #12 and attaching the line for rinse back, without performing hand hygiene and changing gloves. 4. On 10/3/2024 at approximately 09:30 AM, an interview was conducted with the Facility Administrator (E #1). E #1 verbally agreed hand hygiene and/or glove changes should be completed in these situations.”

“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: 50688 Based on document review, observation, and interview, it was determined that for 1 of 2 Patient Care Technicians (PCT) observed performing CVC (central venous catheter- used for dialysis access) care, the Facility failed to ensure that CVC care was performed as required. Findings include: 1. On 10/03/2024, the Facility’s policy titled, “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure” (revised October 2024) was reviewed and indicated, “ ...clean exit site with 2% Chlorhexidine Gluconate/70% Isopropyl Alcohol swab for a minimum of 30 seconds... Perform a 15 second hub scrub of the CVC during the process of connecting or disconnecting from the blood lines, including line reversal, or if the patient is disconnected during treatment for any reason.” 2. On 10/3/2024 between 12:00 PM to 2:45 PM, an observational tour of the dialysis treatment area was conducted. At approximately 12:45 PM, the PCT (E #5) was observed performing CVC care. E #5 was observed disinfecting the CVC insertion site on the patient at station #16, using a 2% Chlorhexidine Gluconate/70% Isopropyl Alcohol swab, wiping the site for 9 seconds. 3. On 10/02/2024 between 12:00 PM to 2:45 PM, an observational tour of the dialysis treatment area was conducted. At approximately 12:45 PM, the PCT (E #5) was observed disinfecting the CVC hubs prior to connection at station #16. E #5 disinfected the CVC hub with an alcohol wipe for 4 turns, approximately 3 seconds, before connecting to the blood lines. 4. On 10/03/2024 at approximately 9:45 AM, an interview was conducted with the Facility Administrator (E #1). During a discussion about disinfection time of CVC hubs, E #1 stated “I believe 15 seconds”. E #1 verbally agreed that the employee’s process was not completed per policy.”