Davita Licking River Home Training

“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: 49050 Based on observation, interview, and review of the facility’s policy, the facility failed to ensure patient safety by staff failing to wear gloves when caring for the patient or touching the patient’s equipment at the dialysis station and when performing peritoneal dialysis catheter flush and peritoneal dialysis catheter irrigation utilizing heparin for 1 of 4 sampled patients, Patient (P) 3. On 04/30/2025 at 10:43 AM, Registered Nurse (RN) 1 was observed washing hands and using alcohol based hand sanitizer but failing to wear gloves when cleaning P3’s peritoneal dialysis catheter port, sanitizing the catheter connector, and performing peritoneal dialysis catheter flush. The findings include: Review of the facility’s policy titled, “Peritoneal Dialysis Catheter Flush Procedure,” dated April 2025, revealed, “2. Wash hands, Put on PPE [personal protective equipment], (facemask, eye protection, gloves fluid resistant/fluid impervious barrier garment). Clean work area with 1:100 (one to one hundred) bleach solution. 3. Remove gloves and perform hand hygiene. Gather supplies. 4. Remove dialysate solution from over pouch. Inspect solution for strength, volume, expiration date, leaks, discoloration or other damage. 5. Add heparin to dialysate if prescribed. 6. If not already completed, apply appropriate transfer set per procedure. 7. Perform hand hygiene. Put on clean gloves.” Observation on 04/30/2025 at 10:43 AM revealed Registered Nurse (RN) 1 washed her hands, used alcohol based hand sanitizer but failed to wear gloves when cleaning P3’s peritoneal dialysis catheter port, sanitizing the catheter connector, and performing peritoneal dialysis catheter flush. During interview on 04/30/2025 at 11:58 AM with RN1, she stated she weighed the patient when they arrived. Then, she stated she put on PPE (mask, washed hands), listened to them for fluid, and used hand sanitizer. Before removing the dressing, she stated she washed her hands and put on gloves to remove the old bandage. RN1 stated, “I do not have to wear gloves when setting up the peritoneal catheter flush.” When asked about the facility’s policy when performing care, RN1 stated, “As long as we wash our hands with soap and water and use alcohol based hand sanitizer, I do not need to wear gloves.” When asked if she knew the facility’s policy which stated, “When caring for a patient at a dialysis station, gloves must be worn,” RN1 stated, “No, I was not aware of that policy.” RN1 stated when she was initially trained, she was trained to wear gloves. She also stated, “That is something I will have to correct.” During interview on 04/30/2025 at 3:11 PM with the Administrator, she stated it was her expectation that staff followed infection control procedures to reduce the chance of infection for patients.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 44000 Based on observation, interview, and review of the facility’s policy, the facility failed to appropriately handle and store medications for 1 of 3 medications in the medication cabinet. The findings include: Review of the facility’s policy titled, “Medication Policy,” revised November 2023, revealed, “Disposal of expired medications, including all over the counter and nutritional product samples are removed from the treatment and inventory areas and disposed of per state/local regulations.” Observation on 04/29/2025 at 2:17 PM, during inspection of the medication cabinet, revealed a box of Gentamicin Sulfate 0.1% was expired with an expiration date of 01/2025. During interview with the Administrator at the time of the observation, she stated staff checked medications in the cabinet once a month for expiration dates. She stated staff did not keep a sheet with the medication checks. She stated she did not know why the Gentamicin Sulfate was not removed during the monthly checks.”