Dci - Maysville

“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: 35949 Based on observation, interview, and facility policy review, the facility failed to ensure 4 (Registered Nurse [RN] 3 and Certified Clinical Hemodialysis Technicians [CCHT] 4, 5, and 6) of 4 observed staff performed hand hygiene before they touched patient care equipment (dialysis machine), patient care supplies, and when they moved between treatment stations. Failure to perform hand hygiene provided a mode of cross contamination with the potential spread of pathogens, which could negatively impact the health and well-being of the 28 patients who received dialysis treatments and/or home therapy oversight at the facility. The findings include: Review of the facility’s policy titled, “Hand Hygiene and Use of Alcohol-Based Hand Sanitizers,” issued 10/30/2019, indicated, “Hand Hygiene means cleaning hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, antiseptic hand rub (i.e. alcohol-based hand sanitizer including foam or gel), or surgical hand antisepsis. Hand hygiene should be performed: Before eating; Before and after having direct contact with patient’s intact skin (taking a pulse or blood pressure, performing physical examinations); After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings; After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; If hands will be moving from a contaminated-body [sic] site to a clean-body [sic] site during patient care; After glove removal; and After using the restroom.” Further review revealed, “Staff must remove gloves and wash hands between each patient and station.” The policy continued, “Alcohol-based hand sanitizer is acceptable including but not limited to: After removal of gloves; After touching any patient and/or equipment; After contact with chair side computer keyboards screens (sic) Before contact with a patient; Anytime hands should be washed and are not visibly soiled.” Observations of the dialysis treatment area on 04/09/2025 with the Nurse Manager (NM) revealed the following: - At 9:03 AM, CCHT4 was observed obtaining and applying previously used personal protective equipment (PPE - eyewear) and obtaining and donning (putting on) a pair of gloves without performing hand hygiene. CCHT4 entered Station 8 and touched the dialysis machine. - At 9:10 AM, CCHT5 was observed obtaining and applying previously used PPE (eyewear) and obtaining and donning a pair of gloves without performing hand hygiene. CCHT5 entered Station 1 and touched the patient care supplies. - At 9:12 AM, RN3 was observed obtaining and donning a pair of gloves. RN3 obtained and applied previously used PPE (eyewear) while wearing the same pair of gloves. RN entered Station 7 and touched the dialysis machine. - At 9:32 AM, CCHT6 was observed in Station 1 wearing a pair of gloves. CCHT6 picked up a glove from the floor, discarded the glove, and re-entered Station 1. CCHT6 touched the dialysis machine while wearing the same pair of gloves. - At 9:59 AM, CCHT4 was observed in Station 9 touching the dialysis machine while wearing a pair of gloves. CCHT4 exited Station 9, entered Station 7, and touched the dialysis machine in Station 7 with the same pair of gloves. During an interview on 04/09/2025 at 10:25 AM, CCHT4 stated she was trained and expected to perform hand hygiene when she moved between treatment stations and before she touched patient care equipment. During an interview on 04/09/2025 at 3:30 PM, CCHT6 stated she was trained and expected to perform hand hygiene before she touched patient care equipment. During an interview on 04/09/2025 at 4:03 PM, RN3 stated she was trained and expected to perform hand hygiene before she touched patient care equipment. During an interview on 04/09/2025 at 4:40 PM, CCHT5 stated she was trained and expected to perform hand hygiene before she touched patient care supplies. During an interview on 04/09/2025 at 4:47 PM, the Nurse Manager stated staff was trained and expected to perform hand hygiene before they touched patient care supplies, patient care equipment, and/or when they moved between treatment stations. During an interview on 04/10/2025 at 11:50 AM, the Medical Director stated staff were expected to perform hand hygiene before they touched patient care supplies, patient care equipment, and when they moved between treatment stations.”

“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: 35949 Based on observation, interview, and facility policy review, the facility failed to ensure all environmental surfaces in the dialysis treatment stations were disinfected at the end of each dialysis treatment during 3 of 3 observations. Failure to thoroughly disinfect all environmental surfaces in the dialysis treatment stations had the potential to serve as a vehicle for transmission of infectious disease and negatively impact the safety and wellbeing of the 28 patients receiving dialysis treatments and/or home therapy oversight at this facility. The findings include: Review of the facility’s policy titled, “Routine Disinfection in the Hemodialysis Unit,” issued 10/30/2019, indicated, “Proper cleaning and disinfection of environmental surfaces (including patient chairs or bed surfaces, dialysis equipment surfaces, adjacent tables and work surfaces) must be performed between patient uses to prevent transmission of dangerous pathogens. In hemodialysis units, cleaning and disinfection procedures during patient changeover are particularly prone to error and contribute to risk of cross-contamination if correct procedures are not observed (CMS [Centers for Medicare and Medicaid Services] V122).” Observation of the hemodialysis treatment area on 04/09/2025 revealed the following: - At 9:25 AM, Certified Clinical Hemodialysis Technician (CCHT) 5 was observed disinfecting Station 1. CCHT5 failed to disinfect the sanitizer bottle and bracket and blood pressure (BP) cuff storage basket attached to the side of the dialysis machine. - At 9:27 AM, CCHT6 was observed disinfecting Station 2. CCHT6 failed to disinfect the sanitizer bottle and bracket and BP cuff storage basket attached to the side of the dialysis machine. - At 11:40 AM, CCHT4 was observed disinfecting Station 2. CCHT4 failed to disinfect the sanitizer bottle and bracket and BP cuff storage basket attached to the side of the dialysis machine. During an interview on 04/09/2025 at 12:47 PM, CCHT4 stated she was trained and expected to disinfect all surfaces in the treatment station. During an interview on 04/09/2025 at 3:30 PM, CCHT6 stated she was trained and expected to disinfect all surfaces in the treatment station. During an interview on 04/09/2025 at 4:40 PM, CCHT5 stated she was trained and expected to disinfect all surfaces in the treatment station. During an interview on 04/09/2025 at 4:47 PM, the Nurse Manager stated staff was trained and expected to disinfect all surfaces in the dialysis treatment station after each dialysis treatment, including the sanitizer bottle and bracket and the BP cuff storage basket. During an interview on 04/10/2025 at 11:50 AM, the Medical Director stated staff was expected to disinfect all environmental surfaces in the dialysis treatment station after each dialysis treatment, including the sanitizer bottle and bracket and the BP cuff storage basket.”

“ENVIRONMENT-SECURE & RESTRICTED CFR(s): 494.40(a) 8 Environment: secure & restricted The water purification and storage system should be located in a secure area that is readily accessible to authorized users. The location should be chosen with a view to minimizing the length and complexity of the distribution system. Access to the purification system should be restricted to those individuals responsible for monitoring and maintenance of the system. This Standard is not met as evidenced by: 35949 Based on observation and interview, the facility failed to secure and restrict access to the water purification system to only authorized personnel who were responsible for monitoring and maintaining the water purification system. Unrestricted access had the likelihood to allow unauthorized personnel access to the water purification system and the potential to negatively impact the safety and well-being of the 24 patients who received in-center hemodialysis treatments at the facility. The findings include: Observation on 04/07/2025 between 8:50 AM and 9:20 AM, during the environmental tour, revealed no restriction between the supply storage area and the water purification system. During an interview on 04/09/2025 at 1:10 PM, the Nurse Manager (NM) stated the housekeeping staff was in the facility after business hours and had unrestricted access to the water purification system. The NM stated janitorial supplies were stored in the same area where the water purification system was located. During an interview on 04/10/2025 at 11:50 AM, the Medical Director stated access to the water purification system should be restricted to authorized staff responsible for monitoring and maintaining the water purification system. During a follow up interview on 04/10/2025 at 3:40 PM, the Nurse Manager stated the facility had no policy regarding access restriction for the water purification system.”