Riley Hospital - Peds 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: 44715 Based on observation, record review and interview, the agency failed to ensure employees used proper hand hygiene and PPE in 2 of 2 observations of dialysis supply management and contamination prevention. (Employee: RN 3 (three times) and RN 8). Findings include: 1. An agency policy titled, “Infection Prevention” dated 6/28/2010 and published 9/04/2024 indicated but was not limited to, ... IV. Definitions: ... Standard Precautions: Standard precautions is a set of basic infection prevent practices intended to perevent transmisson of infectious diseases fro one person to another ... Standard precautions include the use of hand hygiene and PPE based on the nature of the patient interaction ... V. Policy Statments: ... D. The hemodialysis machine is considered contaminated even when not in use and thereforewill be handled while wearing gloves. ... VI. Procedures: A. Hand Hygiene is required ... 2. After contact with inanimate objects including medical equipment or environmental surfaces at the patient station. ... 4. Before donning gloves. 5. After donning gloves. ... . 2. On 1/27/2026 at 10:35 AM, RN 3 was observed at Station 2 applying a blood pressure cuff to Patient 4. RN 3 did not don gloves. RN 3 used hand sanitizer and moved to Station 3. 3. On 1/27/2026 at 10:46 AM, RN 3 moved from Station 3 to Station 4 to respond to an alarm on the dialysis machine. RN 3 applied gloves and reset the machine, removed her gloves and moved back to Station 3 without using hand sanitizer. 4. On 1/27/2026 at 1210 PM, RN 3 was observed cleaning the dialysis machine at Station 3. RN 3 reached into her scrub pants pocket to retrieve a pen while wearing gloves. RN 3 made a note and returned the pen to her scrubs and continued to clean the chair without performing hand hygiene. 5. On 1/28/2026 at 7:30 AM, RN 8 responded to an alarm at Station 4 with Patient 2. RN 8 adjusted the patient blood lines without gloves, moved to the dialysis machine to reset the alarm without gloves, performed hand hygiene and moved back to Station 1. 6. On 1/28/2026 at 11:15 AM, the Manager was queried regarding the cleaning of the dialysis station. The Manager indicated anything within the station is considered “dirty” and employees should always wear gloves and utilize hand sanitizer.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 44715 Based on observation and record review the agency failed to ensure employees utilized proper disinfection of the dialysis station post dialysis treatment in 2 of 4 terminal cleanings post hemodialysis observations. (Employee: RN 4 and RN 3). Findings include: 1. An agency policy titled, “Infection Prevention Standards in Hemodialysis”, published 9/04/2024, indicated but was not limited to ... F. Environmental Cleaning 1. At the end of the treatment, all surfaces will be cleaned using an approved hospital disinfectant. ... 4. Empty and disinfect reusable priming waste buckets between patients. ... . 2. On 1/27/2026 at 10:30 AM, RN 4 was observed cleaning the isolation room post hemodialysis treatment of Patient 8. RN 4 was observed emptying the prime container at the wall station and replaced it on the dialysis machine. RN 4 failed to properly dispose of prime container contents in a dirty sink and clean the interior/exterior of the prime container. 3. On 1/27/2026 at 11:50 AM, RN 3 was observed cleaning station 3 post hemodialysis treatment of Patient 2. RN 3 wiped the front of the dialysis machine only. The prime container was not emptied or cleaned. While cleaning the dialysis chair, RN 3 failed to fully recline and open the sides of the chair to disinfect the dialysis chair. 4. On 1/28/2026 at 11:45 AM, the Manager was queried regarding the process of terminally cleaning the dialysis station post treatment. The Manager indicated the process may appear altered as the weekly schedule was changed to accomodate hemodialysis patients on a PD clinic day. When asked if the process for cleaning the dialysis station would vary post hemodialysis treatment regardless of the schedule change, the Manager indicated it would not.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 44715 Based on observation and interview the agency failed to ensure the safety of staff by not providing an eye wash station in the designated water room area for 1 of 1 water rooms. Findings include: 1. On 1/26/2026 at 8:45 AM during the Flash Tour, the water room was located in the basement of the building below the dialysis unit. Staff must ambulate down 2 flights of stairs, utilize a key to gain access, ambulate down 6 metal stairs and across a shared maintenance/storage area for the hospital to access the water room designated area. No eye wash station was present. 2. On 1/26/2026 at 8:50 AM during the flash tour of the water room, Entity 1’s (an acute care hospital) Facilities Manager (Biomed 2), verified no eye wash station existed at or near the designated water room area of the basement. 3. On 1/27/2026 at 6:44 AM while observing the opening of the dialysis unit, RN 4 demonstrated the steps required to prep the water for the unit. This writer and RN 4 ambulated down 2 flights of stairs, down a hallway, where RN 4 unlocked the door for the water room. The designated area is located down 6 metal steps and across a congested maintenance area in the back corner of the basement. When queried if they had ever found issues with the water room, RN 4 verified they had once opened the water room to find water spraying from the reverse osmosis ports. “On that day I had two showers.” 4. During an interview on 01/28/2026 at 11:15 AM with the Unit Manager, they explained if a staff member had an issue requiring assistance in the water room the employee could call the unit and another staff member would go down to assist them. When queried if the situation had impacted their vision, how would one utilize their phone? The Manager agreed the potential could be an issue to consider.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 44715 Based on observation, record review and interview the agency failed to ensure patients were monitored during their dialysis treatments for 2 of 6 patients observed receiving hemodialysis with a central venous catheter. (Patient 2, and 7) Findings include: 1. On 01/27/2026 at 9:27 AM, Patient #2, admitted 10/01/2025, was observed receiving their hemodialysis treatment via a CVC at station #4. Their head covered with a white blanket. At 9:40 AM, the patient’s head remained covered. 2. On 01/27/2026 at 11:05 AM, Patient #2 was observed wearing a mask during their CVC dressing change by RN 4. Upon completion of the CVC dressing change, Patient #2 removed their mask and pulled their blanket over their head. RN 4 failed to remind patient to not cover their head. 3. On 1/28/2026 at 7:50 AM, Patient #2 was observed at station #5 after the initiation of their hemodialysis treatment via a CVC. Patient #2’s head was covered with a white blanket. 4. On 1/28/2026 at 10:04 AM, Patient # 7 was observed at station #6 after the initiation of their hemodialysis treatment via a CVC. Patient # 7’s head was covered with a white blanket. 5. On 1/28/2026 at 11:45 AM, the Manager was queried regarding a patient’s head being covered with a blanket during their treatment. the Manager indicated a patien’ts head should always be visible during the hemodialysis treatment.”