Idf - Parkview Center

“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: 44367 Based on clinical observations, the facility’s administration failed to ensure that the standards of care related to hand hygiene and glove use requirements were complied by all staff who come in contact with the dialysis patients in the facility. This failure placed the patients and staff at potential risk for nosocomial infections (infections acquired while in a healthcare setting). Staff: #3 Findings include: The Center for Disease Control (CDC) recommends that hand washing incorporate rubbing hands together “vigorously” for 15 seconds, and that the use of alcohol-based rubs incorporate covering all surfaces of hands and fingers, until hands are dry; “Even with glove use, hand hygiene is necessary after glove removal because hands can become contaminated through small defects in gloves and from the outer surface of gloves during glove removal.” According to the facility’s policy Connection of the Central Venous Catheter (CVC) [Double Lumen Catheter (DLC)], page 3 step 11, “Remove gloves and perform hand hygiene; Gloves should be removed and hand hygiene should be performed between dirty and clean procedures.” 1. During observation of the clinical treatment area on 11/13/2023 at 10:32 a.m., the surveyor noted that during treatment initiation of a CVC patient at the isolation station, Staff #3 cleaned catheter exit site, removed the dirty gloves and failed to perform hand hygiene. Staff #3 then placed new gloves on to place a clean dressing. The Clinical Manager was informed of the findings on 11/13/2023.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 44367 Based on observations and interviews with staff, the facility’s governing body failed to ensure the acid room and surrounding areas were free from defects. This failure placed the patients, staff and visitors at potential risk of harm including injury or infection. Findings Included: All buildings and building systems must be maintained free from defects and/or hazards to ensure safety and functionality. The integrity of all surfaces, (e.g., countertops, floors, walls) must be intact, clean, and free from damage. Intact surface integrity allows for effective cleaning and free from damage. Intact surface integrity allows for effective cleaning and limits the potential for microbial growth on a porous surface. Observation of the acid storage room and surroundings areas on 11/13/2023 at 1:00 p.m. revealed the following: 1. Corrosive type of damage and an approximately 1.5 inch gap in the floor along the base of the walls, causing an open areas along the wall. 2. An approximately 4 foot by 1 foot corrosive type of damaged area was noted on the floor coming from dispensing pipe at the bottom of the 2 K 2.5 Ca holding tank. 3. An approximately 1 - 1.5 inch gap under the Laundry Chute room’s door that opens to the outside. The gap may potentially allow small pest and/or bug to enter the building. 4. An approximately 3 - 4 inch opening at the lower right corner of the supply room’s bay door. The opening may potentially allow small pest and/or bugs to enter the building. The Clinical Manager and the Biomedical Director were informed of the findings on 11/13/2023.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 44367 Based on observations and a review of the facility’s policies and procedures, the facility’s governing body failed to ensure that the facility is free of expired supplies. This failure placed the patients at potential risk of harm. Findings include: When medications and supplies are no longer needed, they should be disposed of promptly. Healthcare providers should remove expired medications and supplies as quickly as possible to help reduce the chances that others accidentally receive or intentionally misuse them. Inspection of the Peritoneal Dialysis unit on 11/14/2023 revealed the following: 1. 200 BD Syringe Tip Caps, lot number 6180558 2. Three 60 cc Luer Lock Syringe, lot CLN108-01, expired 8/10/2022. 3. Sixty-four (64) Thin wall 18g (guage) x1 inch needles, lot CKDH04-01, expired 3/1/2023. 4. Three (3) Clave Connector, lot number 3814399, expired 10/1/2023. Inspection of the Clinical treatment area on 11/13/2023 and 11/14/2023 revealed the following: 1. Five hundred (500) packs of 17g Hemodialysis Fistula Needles, lot number 191115F2, expired 11/30/2022. 2. One bottle of EZ Check Blood Strips, lot number 101051, expired 9/30/2023. 3. One bag of Antimicrobial hand Soap 800 ml (milliliters), lot number 200940955, expired 4/2022. 4. Two bags of Premium hand Sanitizer 1000 ml, lot number 2106590716, expired 4/2023. The Clinical Manager was informed of the findings on 11/13/2023 and 11/14/2023.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 44367 Based on observations and review of the facility’s policies and procedures, the facility’s administration failed to ensure that the clinical staff practiced the correct infection control protocols during cannulation of a fistula or graft. This failure placed the patient at potential risk of harm in maintaining their vascular access and/or infection. Staff: #1 and #2 Findings included: According to the facility’s policy Cannulation of Fistula or Graft”, page 3 number 8, “Once the cannulation sites have been cleaned, do not touch the cannulation sites again. If the cannulation site is touched, the area must be cleansed again.” 1. During observation of the clinical treatment area on 11/14/2023 at 10:07 a.m., the surveyor noted that during treatment initiation at station 22, Staff #1 touched the patient’s access after the site was cleansed. Staff #1 did not re-clean the cannulation site prior to cannulation. 2. During observation of the clinical treatment area on 11/14/2023 at 10:24 a.m., the surveyor noted that during treatment initiation at station 30, Staff #1 touched the patient’s access after the site was cleansed. Staff #2 did not re-clean the cannulation site prior to cannulation. The Clinical Manager was informed of the findings on 11/14/2023.”