Davita 12th Street Covington 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: 35949 Based on observation, interview, and facility policy review, the facility failed to ensure staff performed hand hygiene when indicated to prevent cross-contamination and the spread of pathogens in 6 (Stations 3, 6, 9, 10, 13, and 17) of 17 hemodialysis treatment stations. Failure to perform hand hygiene provided a mode of cross-contamination with the potential for spread of pathogens, which could negatively impact the health and well-being of the 47 patients who received dialysis treatments at the facility. The findings include: Review of the facility’s policy titled, “Infection Control for Dialysis Facilities,” revised 04/2023, indicated, “Hand Hygiene 1. 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. [id est, that is], plugging/unplugging acid/bicarb lines form [sic] 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.” Observation of the dialysis treatment area with the Facility Administrator (FA) revealed the following: 1. Observation on 06/04/2025 at 10:19 AM revealed Certified Clinical Hemodialysis Technician (CCHT) 3 wore a pair of gloves while in Station 13. CCHT3 touched her personal protective equipment (PPE) eyewear and then touched the dialysis machine. During an interview on 06/04/2025 at 10:35 AM, CCHT3 stated she was trained and expected to perform hand hygiene before touching patients, patient care equipment, and/or supplies. She stated PPE was potentially contaminated once it was donned (put on). 2. Observation on 06/04/2025 at 10:22 AM revealed Registered Nurse (RN) 2 typed on a computer keyboard near Station 17. She then retrieved and donned a pair of gloves, entered Station 17, and touched the dialysis machine. 3. Observation on 06/04/2025 at 10:27 AM revealed Patient Care Technician (PCT) 6 wore a pair of gloves while in Station 3. PCT6 touched her PPE eyewear and then touched the dialysis machine. During an interview on 06/04/2025 at 10:37 AM, PCT6 stated she was trained and expected to perform hand hygiene before touching patients, patient care equipment, and/or supplies. She stated PPE was potentially contaminated once it was donned. 4. Observation on 06/04/2025 at 10:49 AM revealed RN1 retrieved a pair of gloves, placed them on a computer keyboard near Station 10, and performed hand hygiene. RN1 then picked up the gloves from the computer keyboard and donned them. Next, RN1 entered Station 11 and touched the dialysis machine with the contaminated gloves. 5. Observation on 06/04/2025 at 10:50 AM revealed RN2 wore a pair of gloves and a PPE mask while in Station 6. RN2 lowered the mask with her gloved hand, then touched the dialysis machine and bloodlines with the same gloved hand. During an interview on 06/04/2025 at 10:53 AM, RN2 stated PPE was potentially contaminated once it was donned. She stated she was trained and expected to perform hand hygiene before touching patients, patient care equipment, and/or supplies. 6. Observation on 06/04/2025 at 10:55 AM revealed RN1 touched her PPE eyewear with bare hands. RN1 then retrieved and donned a pair of gloves, entered Station 9, and touched the dialysis machine and bloodlines. During an interview on 06/04/2025 at 11:05 AM, RN1 stated she was trained and expected to perform hand hygiene before touching patients, patient care equipment, and/or supplies. RN1 stated she placed a new pair of gloves on a computer keyboard, which was a potentially contaminated surface, before she donned them, entered the station, and touched the dialysis machine. RN1 stated PPE was always potentially contaminated once it was donned. During an interview on 06/04/2025 at 10:25 AM, the FA stated staff was trained and expected to perform hand hygiene before touching patients, patient care equipment, and/or supplies. The FA stated PPE was always potentially contaminated once it was donned. During an interview on 06/05/2025 at 8:33 AM, the Medical Director stated staff was expected to perform hand hygiene before touching patients, patient care equipment, and/or supplies, and after touching potentially contaminated PPE.”

“IC-HBV-ISOLATION-MACHINES/EQUIP/SUPPLIES CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients To isolate HBsAg positive patients, ... dedicate machines, equipment, instruments, supplies, and medications that will not be used by HBV susceptible patients. This Standard is not met as evidenced by: 35949 Based on observation, interview, and facility policy review, the facility failed to ensure all equipment and supplies in 1 of 1 isolation rooms were appropriately labeled to ensure the items were dedicated for use with patients with bloodborne pathogens and to prevent use with susceptible patients. The failure had the likelihood to cause the spread of bloodborne pathogens and had the potential to negatively impact the safety and well-being of the 47 patients who received dialysis treatments at the facility. The findings include: Review of the facility’s policy titled, “Hepatitis B Surveillance, Vaccination, Infection Control Measures, and Isolation Guidance,” revised 04/2024, indicated, “Purpose: To prevent the spread of hepatitis B infections in the dialysis setting.” The policy specified, “19. Equipment/Supplies a. Dedicated ancillary supplies such as blood pressure cuffs, clamps, tourniquets, stethoscope, blood glucose meter, bicarb/dialysate jugs, bleach buckets, sharps’ container, thermometer, pens, centrifuge, and non-disposable items will be used. b. Such supplies will be labeled [isolation] and will remain in the isolation room/area or station and be disinfected after every patient use with 1:100 (one to one hundred) bleach solution.” Observation of the isolation room with the Facility Administrator (FA) on 06/02/2025 at 10:45 AM revealed the following items were not labeled to indicate they were dedicated for use with patients who tested positive for bloodborne pathogens: one dialysis chair, one biohazard bin, one box of personal protective equipment (PPE) masks, one PPE face shield, three blood pressure cuffs, three disinfection soaking bins, one stool, and one emergency disconnection packet. During an interview on 06/02/2025 at 10:47 AM, the FA confirmed the items observed in the isolation room should be labeled “isolation” and dedicated for use in the isolation room only. During an interview on 06/05/2025 at 8:33 AM, the Medical Director confirmed all dedicated items should be labeled “isolation” when used in the isolation room.”

“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, interview, and facility policy review, the facility failed to ensure the water purification and storage system was in a secure area, with access restricted to only authorized personnel who were responsible for the monitoring and maintenance of the system. The failure had the likelihood to allow unauthorized personnel to access the water purification and storage system and had the potential to negatively impact the safety and well-being of the 47 patients who received dialysis treatments at the facility. The findings include: Review of the facility’s policy titled, “Physical Environment,” revised 04/2018, indicated, “Purpose: To provide guidance on the physical environment of dialysis facility and treatment area.” The policy specified, “9. Systems to assure patient safety will be in place, such as a method for patients to call for help from the restrooms and exam rooms. Access to patient treatment areas, water treatment systems, supply storage and dialysis equipment is restricted to authorized personnel only. Access limitation does not preclude visitors or tours by individual(s) authorized and supervised by facility personnel.” Observation on 06/03/2025 at 8:25 AM revealed the Administrative Assistant (AA) entered the room in which the water purification and storage system was located. During an interview on 06/03/2025 at 8:26 AM, when asked if the AA was trained in the responsibilities of the monitoring and maintenance of the water purification system, the Facility Administrator (FA) stated, “I don’t think so.” Observation with the FA on 06/03/2025 at 8:31 AM revealed the door to the room in which the water purification system was located was propped open with a cardboard box, and the room was unattended. During an interview on 06/03/2025 at 8:31 AM, the FA confirmed the door to the room in which the water purification system was located was open, and she acknowledged the unattended room allowed for unrestricted access. During an interview on 06/05/2025 at 8:05 AM, the AA stated when she entered the room on 06/03/2025, she was not aware there was a water purification system access restriction. During an interview on 06/05/2025 at 8:55 AM, when asked if access to the water purification and storage system should be restricted to those staff responsible for the monitoring and maintenance of the water purification and storage system, the Medical Director stated, “Absolutely.””