Dci - South Lexington

“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: 16113 Based on observation, interview, and review of the facility’s policies/procedures, the facility failed to ensure items taken into the dialysis station were disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common area. The findings include: Review of the facility’s policy/procedure titled, “Dialysis Machine Stripping and Cleaning,” revised 12/20/2018, revealed all surfaces of the hemodialysis machine would be cleaned using 1:100 bleach and water solution or a 1:10 bleach water solution, depending on the patient’s status, after each patient had exited the dialysis station and prior to use by another patient. Observation on 05/29/2024 from 9:20 AM to 1:45 PM revealed all 23 hemodialysis machines had one to two preprinted paper adhesive labels on the machines. Further observation revealed the labels contained the patient’s treatment orders. In an interview with the Charge Nurse (CN) on 05/29/2024 at 2:00 PM, the CN stated the labels were placed on the machines at the beginning of the week and were left there until the week-end. The CN stated the adhesive labels remained on the machines between patients and throughout the week. The CN confirmed the adhesive labels could not be disinfected. In an interview with Registered Nurse (RN) 1 on 05/29/2024 at 1:45 PM, RN1 stated the adhesive labels stayed on the patients’ machines between patients and throughout the week. RN1 stated the paper could not be disinfected.”

“ACID CONC MIX SYS-EMPTY ALL/PREV CORROSION CFR(s): 494.40(a) 5.4.4.2 Acid concentrate mixing systems: empty completely/prevent corrosion Acid concentrate mixing tanks should be designed to allow the inside of the tank to be completely emptied and rinsed according to the manufacturer’s instructions when concentrate formulas are changed. Acid concentrate mixing tanks should be emptied completely before mixing another batch of concentrate. Because concentrate solutions are highly corrosive, mixing systems should be designed and maintained to prevent corrosion. This Standard is not met as evidenced by: 16113 Based on observation, interview, and review of AAMI (Association for the Advancement of Medical Instrumentation) requirements, the facility failed to maintain the acid concentrate mixing system to prevent corrosion. The findings include: Review of the AAMI requirements, adopted by reference 42 CFR 494.40 (a) revealed facility policy and practice must maintain the acid concentrate mixing system clean and free of spills of concentrate to reduce the potential of corrosion. Observation of the water treatment area on 05/29/2024 at 12:25 PM revealed the acid concentrate mixing system had a build-up of a white crystalline substance around the opening and on the shoulders of the tank. The white crystalline substance had brownish red specks throughout. In an interview with the facility’s Technical Employee on 05/29/2024 at 12:40 PM, he stated he cleaned the acid concentrate system monthly. According to the Technical Employee, he had not cleaned the tank in about one and a half months. The Technical Employee stated there was no specific policy/procedure for cleaning the tank.”