Martha’s Vineyard Hospital

“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: 44223 Based on observation, document review, and staff interview, the facility failed to ensure that 1 staff member (Registered Nurse [RN] #2) performed adequate infection control practices related to proper glove use and hand hygiene during the discontinuation of dialysis treatment for an arteriovenous fistula (AVF) for 1 patient (#6) observed, out of a total sample of 6 patients. Findings Include: Review of the facility’s policy titled, Infection Control, dated 12/23, indicated the following: *Gloves are required whenever caring for a patient or touching the patient’s equipment. *Hand washing should be performed after gloves are removed and between patients, as well as after touching blood, body fluids, secretions, excretions, and contaminated items. *If hands are not visibly soiled, use of a waterless antiseptic hand rub can be substituted for hand washing. During an observation on 10/21/24 at 10:40 A.M., the surveyor observed RN #2 at Station 1 preparing Patient #6 for the discontinuation of treatment of his/her AVF. RN #2 applied gloves and prepared the patient’s arm by putting a clean drape under the arm. RN #2 placed her two gloved hands on the biohazard container and pulled it into the station. After placing the biohazard container next to the dialysis chair, RN #2 then proceeded to remove the arterial and venous lines from the patient’s left arm with her contaminated gloved hands. RN #2 did not remove her gloves, perform hand hygiene, or apply new gloves before removing the arterial and venous lines from the patient’s arm. During an interview on 10/22/24 at 2:28 P.M., the Nurse Manager said RN #2 should have removed her gloves and performed hand hygiene before discontinuing treatment.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 44223 Based on observation, staff interview, and document review, the facility failed to ensure that 1 staff member (Registered Nurse [RN] #2) wore Personal Protective Equipment (PPE) correctly during times when potential for spurting or splattering of blood, or potentially contaminated substances or chemicals may occur. Findings Include: Review of the facility’s policy titled, Infection Control, dated 12/23, indicated the following: *Staff members will wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting of blood might occur. Protective clothing or gear should be changed if it becomes soiled with blood, body fluids, secretions, or excretions. Protective equipment is to be removed prior to leaving the treatment area. a. During an observation on 10/21/24 at 10:40 A.M., the surveyor observed RN #2 discontinuing treatment for Patient #6 at station #1. The surveyor observed that while RN #2 prepared the patient’s arteriovenous fistula (AVF), RN #2 pushed up the sleeves of her protective gown exposing her arms. She then proceeded to remove the arterial and venous lines from the fistula putting her at risk for potential exposure to blood, potentially contaminated substances or chemicals. During an interview on 10/21/24 at 11:15 A.M., RN #2 said she should not have pushed her sleeves up exposing her arms during the discontinuation process. b. During an observation on 10/21/24 at 11:00 A.M., the surveyor observed RN #2 disinfecting dialysis station #1. During the disinfection process RN #2 did not have on a face shield or face mask causing potential concern for exposure to blood, potentially contaminated substances or chemicals. During an interview on 10/21/24 at 11:15 A.M., RN #2 said she should of had on a face shield and mask when cleaning the dialysis station. During an interview on 10/21/24 at 2:28 P.M., the Nurse Manager said RN #2 should have been wearing a face shield and face mask when she was cleaning the dialysis station and should not have had her arms exposed during the initiation of treatment.”

“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: 10249 Based on observation, staff interview, and policy review, the facility failed to 1.) ensure that 2 of 2 staff members observed (Registered Nurse [RN] #2, and #3), adequately cleaned and disinfected contaminated surfaces, medical devices, and equipment within the dialysis station, therefore increasing the risk for cross contamination of blood borne pathogens; and 2.) ensure that 2 of 3 blood pressure (BP) cuffs were free from lint and debris, to allow for proper disinfection, and reduce the risk of spread of infection. Findings include: Review of the facility’s policy titled, Dialysis Station Routine Disinfection, last revised 12/2023, indicated the following: *It is the policy of the Dialysis Unit to clean the exterior of the dialysis machine after every treatment. The machine will be cleaned with very dilute (1:100) bleach and will have a dwell time of 5 minutes. *Wear clean gloves. *Apply disinfectant to all surfaces in the dialysis station using a wiping motion with friction. *Ensure surfaces are visibly wet with disinfectant. Allow surfaces to dry. *Disinfect all surfaces of the emptied priming bucket. Allow bucket to air dry. *Keep used or potentially contaminated items away from the disinfected surfaces. *Remove gloves and perform hand hygiene. 1. The facility failed to ensure that RN #2 and RN #3 adequately cleaned and disinfected contaminated surfaces, medical devices, and equipment within the dialysis station, therefore increasing the risk for cross contamination of blood borne pathogens. a. On 10/21/24 at 10:55 A.M., the surveyor observed RN #3 disinfect station #3 for the next patient. She was observed disinfecting the hemodialysis machine and hemodialysis chair using 1:100 bleached soaked pads. RN #3 failed to disinfect the back of the dialysis machine, the back of the dialysis chair, the back wall and wall box. During an interview on 10/21/24 at 11:15 A.M., RN #3 said that they disinfect the back of the chair, dialysis machine, and the wall box once a week. During an interview on 10/21/24 at 2:30 P.M., the Nurse Manager said the expectation is that staff would clean and disinfect the back of the dialysis machine and the dialysis chair during the cleaning and disinfection process, between patients. b. On 10/21/24 at 11:00 A.M., the surveyor observed RN #2 disinfect station #1 for the next patient. She was observed disinfecting the hemodialysis machine and hemodialysis chair using 1:100 bleached soaked pads. RN #2 failed to disinfect the basket connected to the right side of the machine, the arm of television, and the patient’s headphones. She also failed to collapse the tray tables on each side of the chair and disinfect in the crevices between the arms of the chair and the tray tables. During an interview on 10/21/24 at 11:15 A.M., RN #2 said she did not collapse the tray tables and does not always do that depending on the patient. During an interview on 10/21/24 at 2:28 P.M., the Nurse Manager said that all parts of the machine and chair should be cleaned. She also said that each patient has their own set of headphones and that they should be cleaned after each treatment and then put in a biohazard bag that is also cleaned. 2. On 2 days of survey, 10/21/24 and 10/22/24, during observation of the treatment area, the surveyor observed the blood pressure (B/P) cuffs at 3 of 3 stations. Two of three blood pressure cuffs were laden with lint which was embedded in the Velcro portion of the B/P cuff, making it difficult to adequately disinfect between patients. During an interview on 10/21/24 at 2:20 P.M., The Nurse Manager said the staff should replace the blood pressure cuffs when they have lint on the Velcro portion of the cuff. 44223”

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 44223 Based on observation, staff interview, and document review, the facility failed to ensure that 1 staff member (Registered Nurse [RN] #2) provided adequate infection control measures regarding arteriovenous fistula (AVF) cannulation for 1 patient (#1) with a fistula/graft observed, out of a total sample of 6 patients. Findings include: Review of the facility policy titled, Access Preparation and Decannulation for AVF and AVG, dated 12/23, indicated the following: *Assessment of the access shall occur prior to skin preparation of needle insertion. *Skin antiseptic applied appropriately. Apply 70% alcohol in rubbing motion for 1 minute immediately prior to needle cannulation. *Do not palpate insertion site once area has been cleaned. *Repeat skin preparation if the site(s) is touched by either the patient or staff once the skin prep has been applied, but the cannulation is not complete. For Patient #1, RN #2 failed to disinfect the upper and lower access sites after palpating. On 10/21/24 at 11:55 A.M., the surveyor observed RN #2 initiate treatment for Patient #1 via an AVF. RN #2 assessed the AVF and chose his/her access sites. She disinfected the lower access site with 4 alcohol prep pads in a circular motion for a total of 60 seconds. She then disinfected the upper access site with 4 alcohol prep pads in a circular motion for a total of 60 seconds. RN #2 then palpated the lower access site (recontaminating the area) and without disinfecting the site cannulated the lower access site. She then palpated the upper access site (recontaminating the area) and without disinfecting the site cannulated the upper access site. After disinfecting the two access sites RN #2 did not change her gloves or perform hand hygiene before proceeding with cannulation. During an interview on 10/21/24 at 12:30 P.M., RN #2 said that she should have disinfected again after palpating the access sites.”