Rrc - Davison

“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: 50585 Based on observation, interview, and record review, the facility failed to ensure staff wore personal protective equipment (PPE) while caring for patients at the dialysis treatment station for 1 (Staff G) of 6 staff members observed resulting in the increased likelihood of staff becoming contaminated with blood or other potential infectious material. Findings include: On 5/20/2025 at 0910, Physician Staff G was observed at station 14 wearing a white lab coat, a pair of gloves, and with no face mask or shield. Staff G began communicating with the patient who had a central venous catheter and touching the dialysis computer screen to review patient information. While at station 14, Staff G did not wear a mask or an impervious gown. Facility Administrator Staff A was immediately queried if physicians were exempt from wearing PPE while taking care of patients at the dialysis treatment station, and they said “no.” On 5/21/2025 at 0950, Chief Medical Officer Staff J was queried if they expected physicians to wear PPE including masks and gowns when caring for patients at the dialysis stations and they said, “I do.” According to the facility’s policy “Personal Protective Equipment,” dated 11/6/2023, “Personal protective equipment including a full-face shield or mask and protective eyewear with full side shield, fluid-resistant gowns, and gloves, must be worn to protect employees from blood or other potentially infectious materials (OPIM).””

“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: 50585 Based on observation, interview, and record review, the facility failed to complete the cleaning and disinfection of a patient treatment dialysis station following a patient’s dialysis treatment for 2 (Stations 3 and 16) of 2 observations of station cleaning resulting in the increased likelihood of transmitting infections to all the patients. Findings include: On 5/19/2025 at 1008, Technician Staff I was observed cleaning and disinfecting the dialysis treatment chair at station 16. Staff I was observed opening the right wing of the dialysis chair, wiping the inside upholstery with a disinfectant and then immediately closing the wing before allowing the disinfectant to dry. Staff I was queried immediately after cleaning the chair on whether the wing should remain open to allow the disinfectant to dry, and Staff I agreed. On 5/19/2025 at 1017, Technician Staff H was observed cleaning and disinfecting the dialysis treatment station following a dialysis treatment at station 3. After cleaning and disinfecting the station and chair, Staff H was observed obtaining supplies for the next scheduled patient at station 3. Staff H was queried if the back counter behind the dialysis chair was disinfected and Staff H replied “No, and I didn’t clean the remote.” On 5/21/2025 at 0950, Chief Medical Officer Staff J was queried if they expected staff to follow all policies and procedures and they revealed “yes.” According to the facility’s policy “Cleaning and Disinfecting the Dialysis Station, dated 9/5/2023, “3. Use a cloth wetted with 1:100 bleach solution or EPA-approved disinfectant to clean and disinfect the dialysis station (chair/bed, tables, machine, television, IV pole, B/P cuff, hand sanitizer dispenser and holder, chaise wall behind chair). Place the chair in Trendelenburg position and open side panels if chair has swing open sides so all surfaces of the chair are accessible. 4. Clean all surfaces. Make the surfaces glisteningly (sic) wet and allow to air dry unless otherwise specified by the manufacturer.””