Davita Crooked Creek - Marshville

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 35306 Based on policy and procedure review, observation, and staff interview, the facility staff failed to prevent cross-contamination in 2 of 2 observations of CVC exit site care (Patient #6 and #7). Findings included: Review on 1/29/2025 of the facility policy, “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure” revised October 2024, revealed “... 8. Holding catheter with the non-dominant hand and using aseptic technique, clean exit site with 2% Chlorhexidine Gluconate/70% Isopropyl Alcohol swab for a minimum of 30 seconds, apply to the CVC exit site in a “back and forth” pattern, using gentle friction progressing from the insertion site to the periphery using both sides of the swab. ...” 1. Observation on 01/29/2025 at 1210, revealed PCT #1 performed exit site care for Patient #6. Observation revealed the PCT began cleansing the exit site with a Chlorhexidine swab, starting from the periphery 2 to 3 inches above the exit site using a “back and forth” motion and cleaned back toward the exit cite. The PCT repeated the same motions of cleansing several inches below the exit site, beginning at the periphery and cleaned back toward the exit site. Interview on 01/29/2025 at 1645 with PCT #1, revealed exit site care was performed using the method taught in a training video, demonstrating CVC exit site care, during orientation. PCT #1 shared that it is “difficult not to return to the exit site using those motions.” Interview on 01/29/2025 at 1900 with the FA, revealed the expectation was “that staff follow the policy and cleanse the exit site progression from the insertion site to the periphery. We don’t do a lot of these (CVC) so we will do some retraining. The training video needs to be updated or pulled from our orientation packet so that our staff don’t get confused.” 2. Observation on 01/29/2025 at 1250, revealed PCT #2 performed exit site care for Patient #7. Observation revealed the PCT began cleansing the exit site with a Chlorhexidine swab, starting from the periphery 2 to 3 inches above the exit site using a “back and forth” motion and cleaned back toward the exit cite. The PCT repeated the same motions of cleansing several inches below the exit site, beginning at the periphery and cleaned back toward the exit site. Interview on 01/29/2025 at 1645 with PCT #2, revealed exit site care was performed using the method taught in a training video, demonstrating CVC exit site care, during orientation. PCT #2 shared that it is hard not to return to the exit site when we’re cleansing the site in a back and forth motion. I like the thought of cleansing the exit site using the half-moon technique. We should not return to the exit site once we’ve cleansed the periphery.” Interview on 01/29/2025 at 1900 with the FA, revealed the expectation was “that staff follow the policy and cleanse the exit site progression from the insertion site to the periphery. We don’t do a lot of these (CVC) so we will do some retraining. The training video needs to be updated or pulled from our orientation packet so that our staff don’t get confused.””

“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: 35306 Based on policy and procedure review, manufacturer instructions for use (IFU) review, observation, equipment log review, and staff interview, the facility failed to ensure preventive maintenance for the eye/face wash station and drench shower/hose was performed, failed to ensure the On Demand Bleach Autodilution system met requirements according to the facility’s protocol and manufacturer specifications, and failed to ensure Quality Control tests were performed. Findings included: 1. Review on 01/29/2025 of the facility’s policy, “EYEWASH STATION/SINK/DRENCH SHOWER/HOSE CHECKS” (Revision Date: October 2019), revealed “... 1. ... Self-contained stations are to be inspected according to the manufacturers’ specification... Annual inspections are documented on the Annual Eyewash and Drench Shower/Hoses Inspection log. Logs are maintained by the facility.. 8. Eyewash equipment should be capable of delivering to the eyes a minimum of 1.5 liters (0.4 gallons) per minute for 15 minutes. For the drench shower/hose operation, equipment should be capable of delivering to the body a minimum of 11.4 liters (3 gallons) a minute for 15 minutes. NOTES: After installation of each new eyewash equipment, equipment will be checked for a period of 15 minutes ... After installation of new drench hoses, drench hose(s) will be checked for a period of 15 minutes ... Documentation of this inspection will be kept in the facility’s Equipment Maintenance Repair Manual. ...” Observation on 01/28/2025 at 1320 in the ICHD treatment area revealed one eye/face wash station and one eye/face wash station in the Home Training area. When the eye/face wash station located in the treatment area was activated, the back dust cover failed to open. Observation revealed a hinge was broken on one side, preventing the dust cover from opening. Observation on 01/282025 at 1630 in the water room revealed one drench shower. Review of the preventive maintenance (PM) “Ticket Summary” dated 02/21/2024 revealed an annual inspection of the eyewash stations and drench hose and shower was performed. Review of the PM log revealed an annual inspection was not performed in 2023 and that evidence of verification of required flow rates following installation was not available for review. Review of the “Annual Eyewash Inspection” Procedure: 4-08-09B and “Annual Drench Shower/Hoses Inspection” Procedure: 4-08-09C revealed no available documentation of annual inspections for review. Interview on 01/29/2025 at 1500 with the Biomedical Technician (BT) revealed, “We do not have annual inspections for 2023. We discovered the contracted agency who use to perform those inspections, dropped them from their scope of services and we (BioMed) picked up the responsibility for conducting those last year.” Interview on 01/29/2025 at 1730 with the facility’s Medical Director (MD) revealed that closer attention to manufacturer recommendations was indicated and that facility policy should reflect and align with maintenance specifications. Interview confirmed facility policy was not followed. 2. Review on 01/29/2025 of the facility’s policy, “ON DEMAND BLEACH AUTODILUTOR” Policy: 2-10-05, revised October 2013, revealed “...3. The water source must be turned on and the pressure must be between 28-78 psi ] pounds per square inch: unit of pressure measurement]. ...” Review on 01/29/2025 of the “On Demand Bleach Autodilutor Verification Log” revealed no evidence of psi verification noted on the log available for review. Observation on 01/29/2025 at 1630 in the ICHD treatment area revealed one On Deman Bleach Autodilutor. Observation revealed there were no gauges available on or around the system to measure the psi. Interview on 01/29/2025 at 1500 with the BT revealed, “I was not aware of that requirement and don’t know who installed it. But there had never been a gauge on or near the Autodilutor for verification of the psi. “I can’t find a t-intersection piece for the pressure gauge that will fit and there’s no way for use to measure that without a gauge.” Interview on 01/29/2025 at 1730 with the facility’s Medical Director (MD) revealed that closer attention to manufacturer recommendations was indicated and that facility policy should reflect and align with maintenance specifications. Interview confirmed facility policy was not followed. Interview on 01/29/2025 at 1900 with the FA revealed she was not aware of the facility’s protocol specifying the psi range requirements or manufacturer specifications. 3. Review on 01/25/2025 of the facility’s procedure, “PREPARATION OF 1% OR 10% BLEACH SOLUTION UTILIZING THE ON DEMAND BLEACH AUTODILUTION SYSTEM” Procedure: 1-22-07A, (Revision Date: October 2015), revealed “... Materials required: ... WaterCheck, CP Bleach Strip” ... 10. Test dispensed solution using WaterCheck CP Bleach Strip per test strip instructions. ...” Review on 01/25/2025 of the “WaterCheck CP Reagent test strip...” IFU revealed, “... QUALITY CONTROL: ... Perform QC [Quality Control] control only on one bottle from the 6 bottles in the box of the same lot number. ...” Observation on 01/24/2025 at 1142 during tour of the treatment area revealed one On Demand Autodilution System. One bottle of WaterCheck CP chlorine, peroxide and chlorine dioxide reagent test strips, lot number 2301146001, was located on the countertop beneath the autodilution system. Further observation revealed a box with five unopened bottles of test strips, lot number: 2304149001, in the cabinet beneath the system. Review on 01/25/2025 at 1155 of the On Demand Bleach Autodilutor Verification Log revealed PCT #1 was responsible for testing the autodilution system dispensed solution. Review failed to reveal documented evidence that quality control checks were performed and documented per manufacturer recommendations. Interview on 01/26/2025 at 1305 with PCT #1 revealed the PCT was not aware of the manufacturer IFU regarding the requirement for performing quality control tests on the WaterCheck CP Chlorine/Peroxide Reagent strips. Interview on 01/26/2025 at 1900 with the FA revealed, “I’ll be honest, I was not aware [of the requirement for performing quality control tests on the WaterCheck CP Chlorine/Peroxide Reagent strips]. I assumed Biomed addressed that with staff [PCT #1].””