Optimal 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: 44232 Based on observation, record review, and interview, the facility failed to ensure the patients were offered or instructed to perform hand hygiene in 3 of 3 observations after holding their access post dialysis treatment. (Patients: #8, #5, and #6) Findings Include: 1. A review of a dated August 2020, Optimal Dialysis policy titled, “Handwashing/Antibacterial Hand Sanitizer” 07-05 indicated but was not limited to, “ ... Wet hands and apply antibacterial soap or sanitizer ... Prevents recontamination of hands ...” 2. On 01-24-2024 at 10:10 AM, a sign was posted on the wall above the clean sink in the treatment area was reviewed. The sign titled “Wash Your Hands” provided pictures and written instructions on how to complete a hand wash which indicated the best practice to prevent infection. 3. During an observation of a discontinuation of dialysis and post dialysis access care for an Arteriovenous Fistula (AV) (a surgical connection between an artery and a vein for dialysis access) on 01-26-2024 at 8:35 AM, Patient #8 was observed at Station #4, holding pressure with a right gloved hand to their left lower AV access site. The Registered Nurse (RN) 1, was observed to remove Patient #8’s glove, obtain their blood pressure, and obtain the patient’s weight from the scale. Patient #8 left the treatment area and was not offered hand sanitizer nor instructed to perform hand hygiene. 4. During an observation of a discontinuation of dialysis and post dialysis access care for an AV Fistula on 01-26-2024 at 9:01 AM, Patient #5 was observed at Station #2, holding pressure with a right gloved hand to their left upper AV access site. Patient #5 removed their glove discarded the glove in the trash receptacle and left the treatment area. Patient #5 was not offered hand sanitizer nor instructed to perform hand hygiene. 5. During an observation of a discontinuation of dialysis and post dialysis access care for an AV Fistula on 01-26-2024 at 2:10 PM, Patient #6 was observed at Station #2, holding pressure with a right gloved hand to their left upper AV access site. Patient Care Technician (PCT 1), was observed to remove Patient #6’s glove, obtain their blood pressure, and assist Patient #8 to the scale. Patient #6 was assisted by the PCT out of the treatment area and was not offered hand sanitizer nor instructed to perform hand hygiene. 6. During an interview on 01-26-2024 at 2:40 PM, RN 1 and PCT 1, confirmed the patients are to be offered or instructed to perform hand hygiene after the patients held pressure on their access site with a gloved hand.”

“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: 47343 Based on observation and interview, the agency failed to properly manage the handling of expired supplies in 1 of 1 stand alone dialysis in-center facilities. Findings Include: 1. During an observation on 01-24-2024 at 2:30 PM, noted in a drawer under the centrifuge (a machine using force to mix the samples) 5 vacutainer safety-loks with an expiration date of 04-30-2023. 2. During an observation on 01-24-2024 at 2:45 PM, noted in a drawer under the medication refridgerator was an infusomer 5 pace pump Y-type with an expiration date of 06-30-2023. 3. During an interview with Registered Nurse (RN) 1 on 01-24-2024 at 3:19 PM, they indicated the supplies had expired.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 44232 Based on observation, record review, and interview, the facility failed to provide a safe environment for 1 of 1 stand alone dialysis treatment centers. Findings Include: 1. A review of a dated August 2020, Optimal Dialysis policy titled, “Medications Requiring Refrigeration” 06-24 indicated but was not limited to, “ ... The refrigerator is checked twice daily, during facility normal operating hours, for cleanliness ... “ 2. A review of a dated August 2020, Optimal Dialysis policy titled, “Obtaining A Blood Culture During A Hemodialysis Treatment” 01-42 indicated but was not limited to, “ ... Verify that blood culture bottles have not expired ... “ 3. A review of facility documents titled “Monthly OSHA and Safety Checklist” indicated a walk-through inspection audit of the facility was completed on January 15, 2024, and signed by the Administrator. The checklist indicated but was not limited to, “ ... Are all floors and hallways free of hazards? Check marked yes ... Are all chemicals stored appropriately? Check marked yes ... Is the storage room floor uncluttered? Check marked yes ... Is all floor stock on pallets? Check marked yes ... “ 4. During a flash tour observation of the water room on 01-24-2024 at 8:45 AM, observed a torn open box labeled Baxtor which contained bicarbonate containers on the floor by the back door. During an interview on 01-24-2024 at 9:00 AM, the Biomed Technician confirmed the box was damaged bicarbonate units and was being thrown out and should not be on the floor. 5. On 01-24-2024 at 1012 AM, observed on the top shelf of the lab supply cabinet contained 2 vials of gold top vials expired 12-04-2023, 8 vials of BD Bacterial Cultural vials expired 11-16-2023. During an interview on 01-24-2023 at 10::12 AM, the Registered Nurse (RN) 1 confirmed the lab vials had expired and indicated the Administrator monitored the lab supplies for expired items. 6. On 01-24-2024 at 10:15 AM, during the flash tour, the medical lab area refrigerator was found to have dust and debris on the bottom shelf. The shelf above held a patient specimen tray with 1 lavender, and 4 gold-top blood-filled tubes. Observed a red-brown substance on the bottom shelf of the refrigerator door. During an interview on 01-24-2024 at 10:15 AM, RN 1 confirmed there was a red-brown substance on the refrigerator door and cleaned the area with a bleach-soaked cleaning cloth. 7. During an interview on 01-26-2024 at 9:-00 AM, the Administrator confirmed the debris and dust at the bottom of the refrigerator was from the floor when opening and shutting the door. 47343 8. During a flash tour of the water room on 01-24-2024 at 8:47 AM, a bag labeled “Spill kit” was observed on the floor in the water room’s storage room. 9. On 01-24-2024 at 2:30 PM, 2 boxes were observed on the floor under the centrifuge (a machine used to separate blood samples by density). 10. On 01-24-2024 at 2:45 PM, a box of initiation kits were observed on the floor under the Patient Care Technician’s desk. During an interview with the Biomedical Technician on 01-24-2024 at 9:22 AM, they indicated boxes were not to be on the floor and were to be on a shelf. 11. During a flash tour of the water room’s storage room on 01-24-2024 at 8:47 AM, the third shelf from the top had white crystals and crust covering it. During an interview with the Biomedical Technician on 01-24-2024 at 9:22 AM, they indicated the white crystals were possibly from a bicarbonate spill and was to be cleaned up.”