Usrc Kokomo 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: 44230 Based on observation, record review, and interview, the facility failed to ensure staff were following standard hand hygiene protocol to prevent the spread of communicable disease for 2 of 2 CVC observations (Patient #3, 6) and 1 of 2 Arterial Venous Graft (AVG) (permanent dialysis access) observations. (Patient #7) Findings Include: 1. A policy titled, “Hand Hygiene” (08/2020) indicated that hand hygiene will be performed before and after touching a patient, prior to contact with vascular access sites, before clean/aseptic procedures (vascular access cannulation), after body fluid exposure risk, after gloves are removed, after contact with inanimate objects, including medical equipment or environmental surfaces at the patient station, when moving from a contaminated body site to a clean body site of the same patient, and after handling biohazardous waste. 2. A policy titled, “Infection Control and Precautions for All Patients” (07/2023) indicated staff will perform hand hygiene using soap and water or antimicrobial hand sanitizer before/after all patient contact and before applying and after removing PPE (personal protective equipment), including gloves. Hand hygiene will also be performed after contact with integrated keyboard or chairside computer, regardless of whether contact occurred through gloved or ungloved hands. 3. During an observation on 05/05/2025 at 10:00 AM, PCT 4 initiated Patient #6’s CVC dialysis treatment. With gloved hands, PCT 4 went from patient care to the integrated keyboard failing to remove gloves and complete hand hygiene. 4. During an observation on 05/05/2025 at 10:34 AM PCT 5 initiated Patient #3’s CVC dialysis treatment. With gloved hands, PCT 5 went from patient care to the integrated keyboard several times failing to remove gloves and complete hand hygiene between tasks 5. During an observation on 05/07/2025 at 10:30 AM, RN 1 initiated treatment for Patient #7 using his/her AVG. After entering information on the dialysis machine via the integrated keyboard with gloved hands, RN 1 removed his gloves and left the station to retrieve a clean pad to place under Patient #7’s arm. Hand hygiene was not performed with glove removal. Upon returning to the station, new gloves were applied without hand hygiene being performed. The clean pad was placed under Patient #7’s arm. RN 1 then noted the pre-made pack sitting on the patient’s side table was missing clamps and left the patient station with gloves on to retrieve two clean clamps. Using the same gloves, RN 1 then disinfected the cannulation (needle insertion) sites using an alcohol pad. Next, he palpated the access to assess needle placement and cannulated the patient. RN 1 failed to re-disinfect the access prior to needle placement. 6. During an interview on 05/05/2025 at 10:41 AM, PCT 5 indicated that hand hygiene should be completed between patient care and integrated keyboard use, between patients, and anytime gloves are removed. 7. During an interview on 05/07/2025 at 11:20 AM, PCT 1 indicated that the computer is considered a clean area and hand hygiene should be completed between patient care and keyboard use. 8. During an interview on 05/07/2025 at 11:45 AM, RN 1 indicated that staff are expected to complete hand hygiene between patient care and touching the machine and/or keyboard. RN 1 also indicated that staff should not retrieve clean supplies with dirty gloves on, gloves should be removed and hand hygiene completed first.”

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 44230 Based on record review and interviews, the facility failed to ensure Tuberculosis (TB) (airborne respiratory infection) testing was completed for 2 of 3 personnel files reviewed. (PCT 5, FA) Findings Include: 1. A policy titled, “TB Surveillance Testing - Employee” (02/2023) indicated new hire, baseline, TB testing should include a two-step Tuberculin Skin Test (TST) on or within 10 days of the hire date unless the employee provides evidence of a previous negative TB test. 2. The personnel file reviewed for PCT 5, date of hire 01/30/2024, indicated that the facility failed to administer a TB skin test upon hire. A TB skin test was administered on 02/02/2025 but failed to administer a second step TB test. 3. The personnel file reviewed for the FA, date of hire on 03/31/2025, indicated that the facility administered a one-step TB skin test on 03/07/2025 upon hire but, failed to administer the second step TB test. 4. An interview on 05/07/2025 at 12:22 PM, the FA indicated that a second step TB test is only required if the staff member has never had a TB test completed. No further documentation was provided.”

“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: 44230 Based on observation, record review and interview, the facility failed to follow appropriate infection control procedures for 1 of 2 CVC (dialysis catheter access) treatment initiations. (Patient #6) Findings Include: 1. A policy titled, “Dialysis Catheter Dressing Change Procedure” (02/2023) indicated when disinfecting the catheter exit site, using aseptic technique, cleanse the skin surrounding the exit site with ChloraPrep (skin disinfectant) using gentle back and forth strokes, progressing from catheter exit site outwards for 30 seconds. 2. During an observation on 05/05/2025 at 10:00 AM, PCT 4 initiated Patient #6’s CVC treatment. PCT 4 disinfected the CVC exit site for ten seconds using Chloraprep. 3. During an interview on 05/05/2025 at 10:17 AM, PCT 4 indicated that the disinfection time for CVC exit site was one minute. 4. During an interview on 05/07/2025 at 11:20 AM, PCT 1 indicated that the CVC exit site should be disinfected with Chloraprep for 30 seconds and allow it to dry. 5. During an interview on 05/07/2025 at 11:45 AM, RN 1 indicated that he disinfects the CVC exit site for 1 minute and did not know what the facility policy stated.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 44230 Based on observation, record review and interview the medical director failed to ensure staff followed policy and procedure related to medication securement and monitoring for expired supplies in 1 of 1 facility reviewed, complete initial nursing assessments per policy for 1 of 1 new patient admissions (Patient #1), complete AVF assessments for 2 of 2 Arterial Venous Fistula (AVF)(dialysis access) observations (Patient #7, #8), and ensure standard infection control practices were followed for 1 of 2 CVC initiations. (Patient #6) Findings Include: Medication Securement 1. A policy titled, “Guidelines for Administration of Medication” (02/2025) indicated medications will be locked in a cabinet or medication refrigerator. 2. During an observation on 05/05/2025 at 11:27 AM, a medication refrigerator housing IV Albumin (medication used to treat low protein levels and assist with fluid removal) was found unlocked/unsecured. 3. During an observation on 05/05/2025 at 10:49 AM, a medication cabinet that houses Ondansetron (used to treat nausea), Diphenhydramine (used to treat itching), and Venofer (used to treat anemia) was found unsecured/unlocked. 4. During an interview on 05/07/2025 at 11:20 AM, PCT 1 indicated that all medications should always be secured/locked. 5. During an interview on 05/07/2025 at 11:45 AM, RN 1 indicated that medications are to be always locked. Expired Supplies 1. A policy titled, “Guidelines for Administration of Medication” (02/2025) indicated all supplies and testing strips are to be checked at minimum monthly for expiration and ensure expired supplies are discarded appropriately. 2. A policy titled, “Facility Space/Design & Safety Requirements” (04/2023) indicated staff ensure all supplies and testing strips are checked at least monthly for expiration and discarded appropriately prior to or on the day of expiration. 3. During an observation of the emergency preparedness box on 05/05/2025 at 09:54 AM, 2 Intravenous administration sets were found to have expired on 12/04/2023. 4. During an observation of the treatment floor on 05/05/2025 at 10:23 AM, 14 RPC caps (used to cap patients when they pause treatment) were found to have expired on 03/31/2025. 5. During an observation of the treatment floor on 05/05/2025 at 10:46 AM, 7 white top laboratory tubes and 1 purple top laboratory tube were found to have expired on 05/02/2025. 6. During an observation of the water room on 05/05/2025 at 11:24 AM, one opened bottle of RPC Chlorine Testing Strips (used to test for Chlorine in purified water for dialysis) containing 8 strips inside were found to have expired on 03/31/2025. The vial of RPC strips were located on a cart where testing chlorine testing is completed. 7. During an interview on 05/05/2025 at 11:33 AM, the FA indicated that she is responsible for checking for expired supplies along with the Biomed and Administrative Assistant and that all expired supplies should be discarded. 8. During an interview on 05/05/2025 at 12:58 PM, the Biomed indicated that the PCTs should be checking the strips for expiration dates prior to using them. 9. During an interview on 05/07/2025 at 11:20 AM, PCT 1 indicated that whoever is doing the water checks should be checking the expiration date on the strips. PCT 1 also indicated that whoever is stocking supplies on the treatment floor is responsible for checking expiration dates. 10. During an interview on 05/05/2025 at 11:45 AM, RN 1 indicated that the Biomed is responsible for checking the storage room for expiration dates, RN 1 is responsible for checking the treatment floor for expiration dates, and the Administrative Assistant checks the emergency supplies. Nursing Initial Assessment 1. A policy titled, “Medical Records” (02/2023) indicated an initial nursing history and assessment is to be completed prior to the first dialysis treatment. 2. The medical record for Patient #1 indicated an admission date of 03/14/2025, their first dialysis treatment. 3. A treatment sheet dated 03/14/2025 for Patient #1 indicated the start of treatment at 4:02 PM. 4. A document titled, “Nursing History and Assessment” for Patient #1 indicated a nursing assessment is to be completed prior to initiation of the first dialysis treatment. The assessment was dated 03/14/2025 at 4:33 PM. 5. During an interview on 05/07/2025 at 11:45 AM, RN 1 indicated that the initial patient assessment is completed right after treatment is started. AVF Disinfection/Auscultation 1. A policy titled, “Assessment and Cannulation for AVF Fistula/Graft and Patient Self Cannulation” (10/2023) indicated the access to be cannulated should be assessed for bruit (access sound) using a stethoscope. Staff should locate the needle cannulation sites via palpating the access prior to skin disinfection; remove gloves, perform hand hygiene, don clean gloves, and disinfect each access site utilizing an alcohol pad at least 30 seconds 2. During an observation on 05/05/2025 at 11:48 AM, PCT 4 disinfected Patient # 8’s fistula access site with an alcohol prep for 10 seconds. 3. During an observation on 05/07/2025 at 10:30 AM, RN 1 failed to listen to Patient #7’s fistula prior to cannulating the access site. 4. During an interview on 05/07/2025 at 11:20 AM, PCT 1 indicated that the fistula access site should be disinfected for 30 seconds, and staff should be assessing the site by palpating, auscultation, and visualizing the site. 5. During an interview on 05/07/2025 at 11:45 AM, RN 1 indicated that the fistula access site should be disinfected with alcohol for 15-30 seconds. Infection Control 1. A policy titled, Accessing and De-Accessing the Dialysis Catheter” (06/2024) indicated the procedure for accessing and de-accessing the dialysis catheter should be completed using aseptic techniques to avoid potential catheter contamination or injury. 2. During an observation on 05/05/2025 at 10:06 AM, PCT 4 was accessing Patient #6’s CVC when her face shield fell onto the clean field. PCT 4 picked up the face shield and continued with care, failing to dispose of contaminated supplies and obtaining new supplies. 3. During an interview on 05/5/2025 at 10:17 AM, PCT 4 indicated that she should have disposed of the supplies after dropping her face shield onto the clean field and retrieved new supplies. 4. During an interview on 05/07/2025 at 11:20 AM, PCT 1 indicated that the supplies should have been disposed of, and new supplies retrieved. 5. During an interview on 05/07/2025 at 11:45 AM, RN 1 indicated that staff would be expected to dispose of contaminated supplies and replace with new.”