Davita Fall Creek

“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: 44232 Based on observation, record review, and interview, the agency failed to ensure staff instructed the patients on proper use of hand hygiene after holding their access with a gloved hand during 4 of 5 post dialysis access care for arteriovenous fistula or graft (AVF). (Patients: #1, 13, 14 and 17) Findings Include: 1. A review of a DaVita Inc. policy with a revision date of April 2023, titled, “Infection Control For Dialysis Facilities” indicated but was not limited to, “Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment ...Patients are encouraged to wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis and wash their hands after treatment before leaving the treatment area ... “ 2. During a flash tour of the treatment floor on 07/21/2025 at 8:00 AM, noted a sign above the clean sink of the treatment floor entrance that stated, “Wash Your Hands and Access.” 3. A review of a facility document titled “Training/Inservice Documentation Form” dated 07/23/2025, indicated the summary of training presented had been hand hygiene and glove usage. The Training/Inservice sign in form contained the signatures of the FA in training, RN 1, RN 2, PCT 1, PCT 4, PCT 6, and PCT 7. 4. On 07/21/2025 at 2:50 PM, PCT 1 was observed applying a clean dressing to Patient #14’s right lower access after the patient held pressure with their left gloved hand. Patient #14 removed their glove and discarded it in the trash receptacle, and PCT 1 assisted Patient #14 to their wheelchair. Patient #14 was not instructed or offered hand hygiene prior to leaving the treatment floor. 5. On 07/21/2025 at 3:20 PM, LPN 1 was observed applying a clean dressing to Patient #13’s left lower access after the patient held pressure with their right gloved hand. Patient #13 removed their glove and discarded it in the trash receptacle. Patient #13 was not instructed or offered hand hygiene prior to leaving the treatment floor. 6. On 07/21/2025 at 3:55 PM, RN 1 was observed applying a clean dressing to Patient #1’s left lower access after the patient held pressure with their right gloved hand. PCT 1 removed Patient 1’s glove and discarded it in the trash receptacle. Patient #1 went to the scale to obtain their weight, laid the weight strip on the chairside table, and left the treatment floor. Patient #1 had not been instructed or offered hand hygiene prior to leaving the treatment floor 7. On 07/23/2025 at 8:35 AM, PCT 1 was observed applying a clean dressing to Patient #17’s left lower access after the patient held pressure with their right gloved hand. PCT 1 removed Patient 17’s glove and discarded it in the trash receptacle. Patient #17 was assisted by PCT to the scale and out the treatment room door. Patient #17 had not been instructed or offered hand hygiene prior to leaving the treatment floor. During an interview on 07/23/2025 at 9:35 AM, when questioned regarding the infection control audits and when hand hygiene is to be completed, LPN 1 communicated hand hygiene should be completed upon touching a patient, touching a machine, discarding or donning gloves, and the patients should be completing hand hygiene when they enter or leave the treatment area.”