Davita Clarkston 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: 15195 Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene between all glove changes per facility policy, resulting in the potential for spread of infectious agents to the twelve patients dialyzing at the time. Findings include: On 3/19/24 at approximately 1100, Staff H was observed putting a patient on dialysis at station #10. Staff H was observed changing gloves without performing hand hygiene more than five times. Interview with Staff H, on 3/19/24 at approximately 1120, revealed that he was unaware that he had not performed hand hygiene after each glove change. The facility policy titled “Infection Control For Dialysis Facilities, #1-05-01, revised 4/2023,” documented “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...””

“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: 38269 Based on observation, interview, and policy review, the facility failed to ensure that staff removed personal protective equipment when leaving the treatment area, resulting in the potential to spread infectious disease, among all patients, staff and visitors present at the time of observation. Findings include: On 03/19/24 at 0935, upon survey entrance, Staff Q was observed in the front office wearing a white gown, her personal protective gown (Personal Protective Equipment/PPE). Upon being queried Staff Q stated, “as far as I know, yes, it is acceptable to wear my gown in the office/lobby area.” On 03/19/24 at 1106, Staff P Certified clinical hemodialysis technician (CCHT) was observed exiting the treatment room and entering the lobby area wearing personal protective equipment (PPE, cover gown, and face shield). On 03/19/24 at 1108, Staff F Registered Nurse (RN) was observed exiting the treatment room and entering the lobby while wearing PPE. At the time of observation Staff F was asked if the lobby was considered a clean area and if it was acceptable practice to wear PPE into a clean area. Staff F indicated she was unaware that PPE should not be worn in a designated clean area. On 03/19/24 at 1115, Staff A RN clinic manager was asked if this was acceptable practice, she stated “we always have, and no one has ever said we shouldn’t.” On 03/19/24 at 1400 Staff C the regional operations director was queried regarding when PPE should be worn and when/where PPE should be removed, Staff C stated, “PPE should not be worn in designated clean areas. I think it got all muddled up during covid. An in-service will be done, and this will be corrected.” Policy: 1-05-01 Title: “Infection Control for Dialysis Facilities” Origination date: September 2007...Revision date: ...April 2023 PPE (i.e., gown, gloves, eye protection, face shield) 5. Appropriate PPE will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment, and environmental surfaces, for example, patient care areas. PPE is to be: a. Removed prior to leaving the treatment area. b. Removed as soon as possible if overtly contaminated and i. Disposable, deposit in a biohazard waste container ii. Non-disposable, properly disinfect and place in designated area. c. PPE is not to be worn in non-treatment areas, for example, teammate lounge, teammate offices.”

“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: 15195 Based on observation, interview, and record review the facility failed to ensure staff clean and disinfect contaminated surfaces resulting in the potential to spread infectious agents to the twelve patients dialyzing at the time. Findings include: On 3/19/23 at approximately 1215 to 1225, Staff N was observed disinfecting the dialysis chair in station 19 without wiping down the exterior sides. Staff E was observed disinfecting the dialysis machine in station 19 without disinfecting the prime bucket. Interview with Staff E, on 3/19/24 at 1226, regarding the prime bucket revealed that she “forgot” to do it. Also, interview with Staff N, on 3/19/24 at approximately 1230, revealed that she did not recall disinfecting the exterior of the chair. Review of the facility policy titled “Infection Control For Dialysis Facilities, #1-05-01, revised 4/2023,” documented “13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g., control panel; top, front and sides of dialysis machine; touchscreens; countertops)... ii. Priming containers are to be emptied prior to disinfection...”