Davita Jersey City 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: 35949 Based on observation, interview, and facility policy review, it was determined that the facility failed to ensure staff properly perform hand hygiene upon entering the treatment area, before gloving, and before touching patient care equipment during 3 of 6 observations in the treatment area. Findings include: Review of a facility policy titled, “Infection Control for Dialysis Facilities,” last revised in 04/2023, indicated under a “Hand Hygeine [sic]” section, “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, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, e. after interacting with wall boxes (i.e., plugging/unplugging acid/bicarb [bicarbonate] lines form [sic] dialysis machine, changing acid types, when exchanging dialysis machine) f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse.” Observations of the treatment area on 03/28/2024 with the Facility Administrator revealed the following: a. At 9:50 AM, Certified Clinical Hemodialysis Technician (CCHT) #7 entered the treatment area. CCHT #7 obtained and applied a personal protective equipment (PPE) gown and a pair of gloves. CCHT #7 entered Station 13 and touched the computer keyboard. CCHT #7 failed to perform hand hygiene upon entering the treatment area and before gloving. During an interview on 03/28/2024 at 10:27 AM, CCHT #7 acknowledged he was trained and expected to perform hand hygiene upon entering the treatment area and before gloving. b. At 9:55 AM, Registered Nurse (RN) #4 opened a common supply storage drawer in the nurses’ station. RN #4 obtained and applied a pair of gloves, entered Station 16, and touched the dialysis machine. RN #4 failed to perform hand hygiene before gloving and before touching patient care equipment. During an interview on 03/28/2024 at 10:38 AM, RN #4 acknowledged she was trained and expected to perform hand hygiene before gloving and before touching patient care equipment. c. At 10:04 AM, RN #3 entered the treatment area from the supply room while wearing a pair of gloves and carrying a fluid-filled container. RN #3 entered Station 14 and placed the fluid-filled container on the bottom of the dialysis machine. RN #3 then touched the dialysis machine display screen with the same pair of gloves. RN #3 failed to perform hand hygiene upon entering the treatment area and before touching patient care equipment. During an interview on 03/28/2024 at 10:12 AM, RN #3 acknowledged he was trained and expected to perform hand hygiene upon entering the treatment area and before touching patient care equipment. During the observations of the treatment area from 9:15 AM until 11:00 AM on 03/28/2024, the Facility Administrator was interviewed and confirmed staff were trained and expected to perform hand hygiene upon entering the treatment area, before gloving, and before touching patient care equipment. N.J.A.C. 8:43A-24.8(b)”

“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: 35949 Based on observation, interview, and policy review, it was determined that the facility failed to ensure staff disinfected all environmental surfaces in 3 of 3 dialysis treatment stations observed at the end of dialysis treatment. Findings include: Review of a facility policy titled, “Infection Control for Dialysis Facilities,” last revised in 04/2023, indicated, “13. At the end of each treatment, the dialysis station will be cleaned and disinfected” and “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).” Observations of the treatment area on 03/28/2024 with the Facility Administrator revealed the following: a. At 9:30 AM, Registered Nurse (RN) #5 disinfected Station 7. RN #5 failed to disinfect the dialysis machine’s intravenous (IV) pole and prongs, a stethoscope hanging from an IV pole prong, the emergency take-off pack stored behind the television, and the blood pressure storage basket on the side of the dialysis machine. RN #5 also failed to lower both chairside tray tables and disinfect the outside surface of the chair arms and the edges of the chairside tray table. During an interview on 03/28/2024 at 9:48 AM, RN #5 acknowledged the IV pole and prongs, a stethoscope, the emergency take-off pack, and the blood pressure storage basket were not disinfected. RN #5 also acknowledged both chairside tray tables were not lowered and the outside surfaces of the chair arms and the edges of the chairside tray tables were not disinfected. RN #5 confirmed he was trained and expected to disinfect all surfaces in the treatment stations. b. At 10:25 AM, Certified Clinical Hemodialysis Technician (CCHT) #7 disinfected Station 16. CCHT #7 failed to disinfect the dialysis machine’s intravenous (IV) pole and prongs, a stethoscope hanging on an IV pole prong, an emergency take-off pack stored behind the television, and a blood pressure storage basket on the side of the dialysis machine. During an interview on 03/28/2024 at 10:27 AM, CCHT #7 acknowledged the IV pole and prongs, a stethoscope, the emergency take-off pack, and the blood pressure storage basket were not disinfected. CCHT#7 confirmed he was trained and expected to disinfect all surfaces in the treatment stations. c. At 10:36 AM, Registered Nurse (RN) #4 disinfected Station 1. RN #4 failed to lower both chairside tray tables or disinfect the outside surface of the chair arms and the edges of the chairside tray table. During an interview on 03/28/2024 at 10:38 AM, RN #4 acknowledged both chairside tray tables were not lowered and the outside surfaces of the chair arms and the edges of the chairside tray tables were not disinfected. RN #4 confirmed she was trained and expected to disinfect all surfaces in the treatment stations. During an interview on 03/28/2024 at 10:45 AM, the Facility Administrator confirmed all environmental surfaces in the dialysis treatment stations, including the machine’s IV pole and prongs, emergency take-off packs stored behind the television, stethoscopes hanging from the IV pole prongs, and blood pressure storage baskets on the side of the dialysis machines were required to be disinfected. The Facility Administrator also confirmed the chairside tray tables should be lowered and the chairside tray table edges and outside of both chair arms should be disinfected after each dialysis treatment, noting staff were trained and expected to do so. N.J.A.C. 8:43A-24.4(a)”