Statesville Dialysis 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: 32003 Based on policy review, observations, staff interview and personnel worksheet review, the facility staff failed to prevent cross-contamination by failing to ensure patients performed hand hygiene for 2 of 2 AVF/G discontinuation (Patients #19and #21). The findings include: Review on August 28, 2025 of the facility’s policy, “Infection Control Practices for Hemodialysis” revised May 2025 revealed, “Purpose ...Responsibility ...Policy ...Procedure ...Infection Control Practices ...Patient Practice [space] ...Patients should be instructed to wash hands or use hand sanitizer, prior to leaving the patient care area. ...” 1. Observation on August 28, 2025 at 10:30 AM revealed, Patient #21 applied manual pressure with a gloved hand to a left AVF/G access site. Hemostasis was achieved and CCHT #2 applied tape to finish securing the access site. Once tape was applied, the patient went to the scale for a post-treatment weight and exited the in-center treatment area without performing hand hygiene. Review on August 28, 2025 of the personnel worksheet revealed CCHT #2 completed infection control training in April 2025. Interview on August 26, 2025 at 10:45 AM during the entrance conference revealed, the Clinical Manager and another staff member performed infection control audits and no major concerns had been identified. 2. Observation on August 28, 2025 at 11:05 AM revealed, Patient #19 applied manual pressure with a gloved hand to a left AVF/G access site. Hemostasis was achieved and CCHT #3 applied tape to finish securing the access site. Once tape was applied, the patient went to the scale for a post-treatment weight and exited the in-center treatment area without performing hand hygiene. Review on August 28, 2025 of the personnel worksheet revealed CCHT #3 completed infection control training in July 2025. Interview on August 26, 2025 at 10:45 AM during the entrance conference revealed, the Clinical Manager and another staff member performed infection control audits and no major concerns had been identified.”

“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: 32003 Based on policy review, observations and staff interview, the facility staff failed to ensure all buttons on the laboratory coat (PPE) were buttoned up for 1 of 2 nurses during patient care activities (Nurse #2). The findings include: Review on August 28, 2025 of the facility’s policy, “Infection Control Practices for Hemodialysis” revised May 2025 revealed, “Purpose ...Responsibility ...Policy ...Points of Emphasis [space] 1. ...4. Gowns must be worn at all times in the treatment area ...The front must be closed - every button must be buttoned ...” Observation on August 26, 2025 from 11:30 AM through 1:05 PM (95-minutes) and from 3:45 PM through 4:35 PM (60-minutes), Nurse #2 wore a white laboratory coat for barrier precautions during patient care, however, none of the buttons were buttoned up and the coat remained open during patient care activities. Interview on August 26, 2025 at 10:45 AM during the entrance conference revealed, the Clinical Manager and another staff member performed infection control audits and no major concerns had been identified.”

“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: 32003 Based on policy review, observations, staff interview and personnel worksheet review, the facility staff failed to clean and disinfect the and Hansen connectors for 4 of 4 HDM and station disinfections (Station #14, HDM #16; Station #32, HDM #25; Station #35, HDM #9 and Station #31, HDM #6) and failed to disinfect non-disposable equipment for 3 of 3 observations (wheelchair, Hoyer lift and stand-assist). The findings include: A. Review on August 28, 2025 of the facility’s policy, “Infection Control Practices for Hemodialysis” revised May 2025 revealed, “Purpose ...Responsibility ...Policy ...Procedure ...Infection Control Practices ...Patient Practice ...Medication Practices ...Supply Practices ...Cleaning and Disinfection Practices [space] ...The dialysis station (chairs, machines, priming buckets, special bath jugs, acetic acid jugs, clamps, the chase wall and any Tx signs used) must be disinfected with a 1:100 bleach solution between each patient. ...” Review on August 28, 2025 of the facility’s policy, “Infection Control Practices for Hemodialysis” revised May 2025 revealed, “Purpose ...Responsibility ...Policy ...Procedure ...Infection Control Practices ...Patient Practice ...Medication Practices ...Supply Practices ...Cleaning and Disinfection Practices [space] ...Non-disposable equipment (doppler, pulse oximeter, glucometer, stethoscopes, scissors, line clamps, Phoenix meters, Myron L, etc.) taken to the patient’s station must be disinfected with a 1:100 bleach solution or according to the manufacturer’s instructions prior to being returned to a common clean area or used on another patient. ...” 1. Observation on August 26, 2025 at 3:45 PM revealed, CCHT #1 obtained 1:100 bleach cloths to clean and disinfect Station #14, HDM #16. The observation revealed, all non-disposable equipment was cleaned and disinfected except for the Hansen connectors. Interview on August 26, 2025 at 10:45 AM during the entrance conference revealed, the Clinical Manager and another staff member performed infection control audits and no major concerns had been identified. Review on August 28, 2025 of the personnel worksheet revealed CCHT #1 completed infection control training in April 2025. 2. Observation on August 26, 2025 at 3:57 PM revealed, PCT #1 obtained 1:100 bleach cloths to clean and disinfect Station #32, HDM #25. The observation revealed, all non-disposable equipment was cleaned and disinfected except for the Hansen connectors. Interview on August 26, 2025 at 10:45 AM during the entrance conference revealed, the Clinical Manager and another staff member performed infection control audits and no major concerns had been identified. Review on August 28, 2025 of the personnel worksheet revealed PCT #1 completed infection control training in June 2025. 3. Observation on August 26, 2025 at 4:10 PM revealed, PCT #2 obtained 1:100 bleach cloths to clean and disinfect Station #35, HDM #9. The observation revealed, all non-disposable equipment was cleaned and disinfected except for the Hansen connectors. Interview on August 26, 2025 at 10:45 AM during the entrance conference revealed, the Clinical Manager and another staff member performed infection control audits and no major concerns had been identified. Review on August 28, 2025 of the personnel worksheet revealed PCT #2 completed infection control training in April 2025. 4. Observation on August 27, 2025 at 10:05 AM revealed, Nurse #1 obtained 1:100 bleach cloths to clean and disinfect Station #31, HDM #6. The observation revealed, all non-disposable equipment was cleaned and disinfected except for the Hansen connectors. Interview on August 26, 2025 at 10:45 AM during the entrance conference revealed, the Clinical Manager and another staff member performed infection control audits and no major concerns had been identified. Review on August 28, 2025 of the personnel worksheet revealed PCT #2 completed infection control training in April 2025. 5. Observation on August 28, 2025 at 10:20 AM revealed, DT #1 obtained the facility’s wheelchair, presented to Station #27 as Patient #16 treatment was completed. The technician wheeled the patient from the treatment area to the weight scale. Immediately, thereafter, the technician wheeled the patient back into the treatment area for assistance from the staff. Once the patient was stabilized, the technician wheeled the patient back to the weight scale, obtained a post-treatment weight and wheeled the patient to the lobby area for discharge transportation pick-up. Once transportation arrived, the patient was assisted into the vehicle and exited the facility premises. Observation revealed, the wheelchair was returned to the designated storage area - Bay C without being cleaned or disinfected after patient use. Interview on August 26, 2025 at 10:20 AM during the entrance conference revealed, the Clinical Manager and another staff member performed infection control audits and no major concerns had been identified. Review on August 28, 2025 of the personnel worksheet revealed DT #1 completed infection control training in April 2025. 6. Observation on August 28, 2025 at 10:35 AM revealed, DT #1 obtained the facility’s stand-assist equipment, presented to Station #26 for Patient #17 treatment initiation. DT #1 and CCHT #4 used the stand-assist equipment and assisted the patient from the wheelchair to the station chair. Once the patient was settled into the station chair, DT #1 returned the stand-assist equipment to the designated storage area - Bay C without being cleaned or disinfected after patient use. Interview on August 26, 2025 at 10:45 AM during the entrance conference revealed, the Clinical Manager and another staff member performed infection control audits and no major concerns had been identified. Review on August 28, 2025 of the personnel worksheet revealed DT #1 completed infection control training in April 2025. 7. Observation on August 28, 2025 at 11:00 AM revealed, DT #1 obtained the facility’s Hoyer Lift, presented to Station #31 as Patient #21 treatment was completed. DT #1 and CCHT #1 used the lift and assisted the patient from the station chair to the wheelchair. Once the patient was settled into the wheelchair, DT #1 returned the Hoyer Lift o the designated storage area - Bay C without being cleaned or disinfected after patient use. Interview on August 26, 2025 at 10:45 AM during the entrance conference revealed, the Clinical Manager and another staff member performed infection control audits and no major concerns had been identified. Review on August 28, 2025 of the personnel worksheet revealed DT #1 completed infection control training in April 2025.”