Davita Hillsborough 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: 28297 Based on observation, interview, and policy review, it was determined that the facility failed to ensure staff changed gloves after touching contaminated surfaces for one of three survey days. Touching contaminated items without changing gloves had the potential for cross contamination and could affect 14 in-center patients with Central Venous Catheter (CVC) (a plastic tube placed under the skin and into a large central vein, to be used for a short period of time until a more permanent type of dialysis access has been established). Findings include: During observation on 04/01/24 at 3:25 PM, the Clinic Coordinator Registered Nurse was initiating the treatment via a CVC at Station 7 for Patient (P) 8. The Clinic Coordinator Registered Nurse used a syringe to withdrawal blood from the CVC port and reached over to the sharps container and opened the flap on the sharps container to discard the syringe. He/she continued with the initiation process without changing gloves or sanitizing hands. During an interview on 04/01/24 at 3:35 PM the Clinic Coordinator Registered Nurse confirmed the observation and stated he/she should not have touched the sharps container while initiating the treatment via a CVC without changing gloves and sanitizing hands, as it created the potential for cross contamination from the sharps container, that is pulled to the dialysis station and used on multiple other patient treatments, during the day. Observation on 04/01/24 at 3:45 PM revealed Registered Nurse (RN) 1 was discontinuing the treatment via a CVC at Station 9 for P6. RN1 disconnected the arterial line and flushed the port with normal saline in a syringe. RN1 continued with the rinse back of the dialysis treatment. After rinse back was complete RN1 flushed the venous line with normal saline in a syringe. RN1 deposited the syringe in the sharps container and touched the container with gloved hands. RN1 did not change gloves or sanitize hands after touching the sharps container. During an interview on 04/01/24 at 4:00 PM RN1 stated he/she didn’t think that they had touched the sharps container but acknowledged that it would be an increase of contamination of the CVC if contact was made with the sharps container while depositing syringes into the sharp’s containers. Review of the facility policy titled, “Infection Control for Dialysis Facilities,” revised April 2023 indicated, “...All teammates, Physicians, and Non-Physicians will perform hand hygiene ... after contamination with blood and other infectious material ...” N.J.A.C. 8:43A-24.8(b)”

“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: 28297 Based on observation, interview and policy review, it was determined that the facility failed to ensure the patient’s mask was covering his/her nose during the discontinuation of dialysis via a Central Venous Catheter (CVC) (A hemodialysis central venous catheter is a type of access used for hemodialysis. CVC’s are placed under the skin and into a large central vein, preferably the internal jugular veins) for one of two observations. The failure to ensure the mask was covering the nose as required has the potential for contamination of the CVC and increase the risk of infections and could affect 14 of 42 in-patients that have CVC’s in the facility. Findings include: During observation on 04/02/24 at 9:45 AM, Registered Nurse (RN) 2 was at Station 7 discontinuing the treatment for Patient (P) 9 via a CVC. RN1 completed CVC discontinuation, however the patient’s mask remained below his/her nose during the entire discontinuation process. During an interview on 04/02/24 at 10:00 AM, RN1 confirmed the patient’s mask was not covering the nose as required to prevent contamination. During an interview on 04/03/23 at 12:20 PM, the Clinical Coordinator Registered Nurse confirmed it was part of the facility policy for staff and patients to wear a mask covering the mouth and nose during CVC discontinuation of dialysis via a CVC to prevent contamination. Review of the facility policy titled, “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Cap Procedure,” revised October 2023, indicated, “Teammate and patient will wear masks covering the nose and mouth during this procedure. These measures are vital to preventing the exposure of the catheter and exit site to nasal droplets and infectious bacteria such as methicillin-resistant Staphylococcus aureus (MRSA).” N.J.A.C. 8:43A-24.4(a)”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 28297 Based on record review, interview, and policy review, it was determined that the facility failed to ensure one of six sampled patients (Patient (P) 1) signed the plan of care in a timely manner to show the patient participated in the plan of care meeting or was giving information on the Plan of Care. The failure to involve the patient in the plan of care had the potential for the patient to miss opportunities for improved care and could affect eight peritoneal dialysis patients. Finding include: Review of the medical record for P1 revealed the patient was admitted to the facility on 01/16/24 with diagnosis including end stage renal disease (ESRD). The facility completed an initial plan of care on 02/15/24, with all members of the Interdisciplinary Team (IDT) signing the Plan of Care except the patient. Review of the Physician Encounter Report revealed the patient had a clinic visit on 03/20/24, however there was no indication the patient Plan of Care was discussed, and the patient did not sign the care plan at the clinic visit. During an interview on 04/03/24 at 11:25 AM, the Peritoneal Dialysis Nurse confirmed the Plan of Care was not signed off by the patient. He/she stated they had discussed the plan of care with the patient but just failed to have the patient sign off. During an interview on 04/03/24 at 11:45 AM, the Regional Home Manager confirmed the Plan of Care was not signed by P1, however it should have been signed off by the patient within 30 days of the Plan of Care meeting, at the patient clinic visits, to ensure a discussion with the patient had taken place. Review of the facility policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” revised July 2023 indicated, “...The patient’s plan of care will be completed by facility’s interdisciplinary team, including patient or personal representative, and be signed by team members including the patient or the patient’s personal representative. If the patient chooses not to sign the plan of care, this choice will be documented on the plan of care, along with the reason the signature was not provided ...” N.J.A.C. 8:43A-24.4(a)”