Davita Parsons Dialysis Center

“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: 50529 Based on observation, policy review, and interview, the facility failed to ensure staff wore gloves, changed gloves at appropriate times, and performed hand hygiene in between glove changes during patient contact. Failure to perform hand hygiene provided a mode of cross contamination with the potential spread of pathogens (microorganisms that may cause disease or infection) which could negatively impact the overall health and wellbeing of the 34 patients who received dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) treatments at the facility. Findings Include: Review of a policy titled, “Infection Control of Dialysis Facilities,” dated 04/2023, showed that “All teammates, Physicians, and Non-Physician (NPP) will perform hand hygiene a. upon entering and exiting the patient treatment area, 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/bicarb lines form 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.” An observation on 01/28/25 from 6:20 AM to 7:30 AM, showed Staff I, Registered Nurse (RN), failed to perform hand hygiene after touching a patient during a post treatment assessment. Staff I failed to perform hand hygiene prior to donning gloves and proceeded to provide patient care for the next patient. An observation on 01/28/25 at 10:08 AM, showed Staff G, RN, failed to change gloves and perform hand hygiene after providing patient care and before charting treatment information on the computer as required per facility policy. An observation on 01/29/25 at 1:50 PM, showed Staff H, Certified Clinical Hemodialysis Technician (CCHT) touched the dialysis machine and bloodlines with blood/blood products at Station 8 with gloved hands. Staff H, CCHT, failed to remove gloves and perform hand hygiene prior to performing direct patient care. During an interview on 01/29/25 at 9:20 AM, Staff I, RN, stated the expectation is that staff follow facility policy for hand hygiene and confirmed that failure to do so increases the risk of infection and possible patient mortality. During an interview on 01/29/25 at 9:25 AM, Staff A, Facility Administrator, stated that not performing hand hygiene is unacceptable and staff are expected to follow policy. Staff A confirmed that failure to perform hand hygiene increases risk for infection.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [The facility must demonstrate that it follows standard infection control precautions by implementing-] (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 50529 Based on observation, policy review, and interview, the facility faled to contain biohazardous medical waste (blood or other bodily fluids) in a manner to prevent spills/leaks prior to transporting such waste across the treatment floor. Failure to contain medical waste prior to transport provided a potential spread of pathogens (organisms that may cause disease or infection) which could negatively impact the health and well-being of the 34 patients who received treatment at the facility. Findings Include: Review of a facility policy titled, “Medical Waste Management Plan,” revised 10/2023, showed, “Medical waste is healthcare waste that may be contaminated by blood, body fluids or other potentially infectious materials ...it includes but is not limited to ...blood lines ...used hemodialyzers ...gauze sponges, under pads or any other item contaminated with blood ...” Review of a facility policy titled, “Segregation of Medical Waste,” revised 10/2023, showed, “ ...bags are secured, tied with a center knot ...double bagged and placed in the designated medical waste receptacles ...” An observation of the treatment floor on 01/27/25 at 12:15 PM, showed that dialysis stations failed to have individual biohazardous containers for the disposal of medical waste. Staff were observed carrying used dialyzers and bloodlines containing blood/blood products from the dialysis stations across the treatment floor to designated biohazard containers without being contained in a manner to avoid spills/leaks. During an interview on 01/28/25 at 11:38 AM, Staff E, Facility Administrator confirmed that carrying non-contained biohazardous waste across the treatment floor posed an infection control risk with the potential to spread bloodborne pathogens to both staff and patients.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 50529 Based on observation, policy review, and interview, the facility failed to ensure staff disinfected all dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) equipment and other surfaces that could be potentially contaminated with patients’ blood after a dialysis treatment. Failure to ensure all surfaces of the dialysis machine or other objects that could come in contact with a patient are appropriately disinfected provided a mode of potential transmission of bloodborne pathogens (organisms that may cause disease or infection) which could negatively impact the health and well-being of the 34 patients who received dialysis treatments at the facility. Findings Include: Review of a policy titled, “Infection Control For Dialysis Facilities,” dated 04/2023, showed “... At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g., control panel; top, front and sides of dialysis machine; touchscreens; countertops). i. The Wall box, Drain and Water supply lines are considered part of the dialysis delivery system.” An observation of the treatment area on 01/28/25 from 6:20 AM to 7:30 AM, showed Staff F, Certified Clinical Hemodialysis Technician, was at Station 1 and failed to disinfect the counter behind the dialysis machine, the extendable TV/arm, and did not recline and open chair for disinfection as required per facility policy. During an interview on 01/28/25 at 11:38 AM, Staff E, Facility Administrator, confirmed that staff is to disinfect the counter behind the dialysis machine, the TV/arm, and are to recline and open dialysis chairs during disinfection as required per policy and stated that failure to do so could increase the risk of patient infection. During an interview on 01/29/24 at 1:50 PM, Staff C, Clinical Coordinator stated that failing to follow infection control policies is not what staff is taught and increases risk for infection for patients and staff.”

“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: 50529 Based on observation, policy review, and interview, the facility failed to ensure staff followed policy and procedure to reduce infection risk in patients with a Central Venous Catheter (CVC) access (a thin, flexible tube that is inserted into a vein to access the bloodstream) during 1 of 3 CVC care observations. Failure to ensure appropriate infection control practices when caring for a patient with a CVC provided a potential spread of pathogens (organisms that may cause disease or infection) which could negatively impact the health and well-being of any CVC patients who received dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) treatments at the facility. Findings Include: Review of a policy titled, “Central Venous Catheter (CVC) with ClearGuard HD Antimicrobial End Caps,” revised 10/2024, showed “ ... 3. Place the second moisture proof barrier under catheter limbs. Instruct patient to turn head to opposite side of CVC exit site. 4. Remove old dressing and discard ...Remove gloves and discard. Perform hand hygiene per procedure and re-glove ... 9. Clean each CVC limb/cap with a new LARGE alcohol prep pad, starting close to the exit site and finishing with the cap. 10. Remove gloves and discard, perform hand hygiene per procedure and re-glove ...”. An observation on 01/29/25 at 10:13 AM, showed Staff H, Certified Clinical Hemodialysis Technician, (CCHT) failed to remove gloves and perfom hand hygiene after removing an old dressing from an unidentified patient’s CVC site. Staff H, CCHT then opened sterile supplies with the dirty gloves and cleaned the exposed insertion site of the CVC. Staff H, CCHT failed to clean each connection hub with a separate alcohol pad prior to the initiation of treatment per facility policy. An observation at Station 8 on 01/29/25 at 1:50 PM, showed Staff H, CCHT, failed to replace the old moisture proof barrier with a clean barrier to prevent cross contamination of bacteria during the termination of dialysis. Staff H, CCHT touched the dialysis machine and bloodlines then performed direct patient care without changing gloves and performing hand hygiene. During an interview on 01/29/25 at 1:50 PM, Staff B, Clinic Coordinator (CC), confirmed the facility’s policy and procedure for CVC care is to remove the old gloves and perform hand hygiene after removal of the soiled dressing and prior to cleaning the exposed insertion site per facility policy. Staff B confirmed that CVC dialysis initiation required each limb to be cleaned with a new alcohol pad and that using the same one poses a potential for cross contamination.”