322522 Carlsbad Dialysis (Dci)

“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: 51995 Based on record review and observations, the facility failed to ensure proper hand hygiene and disposable glove practices were performed by staff during dialysis treatments (a medical procedure that helps to perform the functions of a kidney when the kidney is no longer able to work properly. It removes waste, excess water and toxins from the blood that are normally filtered out by healthy kidneys) for 2 (P(Patient)1 and 4) of 4 (P1-P4) patients reviewed for infection control measures. This deficient practice could possibly lead to infection in this immunocompromised (a condition where the immune system is not working properly, making it difficult to fight off infections) population. The findings are: A. Based on record review of the facility’s policy titled “Hand Hygiene and Use of Alcohol Based Hand Sanitizers,” dated 05/02/2024, stated “Policy: 1. Staff must remove gloves and wash hands between each patient and station.” B. During an observation on 03/26/2025 at 10:58 AM of P4 in the treatment room at station 1, S (Staff)4, clinical, did not perform hand hygiene nor change gloves after touching the monitor and clipboard; and prior to touching an arteriovenous (AV) access site (a surgical connection made between a vein and an artery that creates a strong connection with the hemodialysis machine). After removing needle from an AV access site, S4 did not perform hand hygiene nor did a glove change prior to touching the monitor and clipboard. C. During an observation on 03/26/2025 at 11:41 AM of P1 in the treatment room at station 22, S4, clinical, did not perform hand hygiene nor glove change were performed after accessing AV access and prior to touching the monitor. D. During an observation on 03/26/2025 at 11:50 AM of P1 in the treatment room at Station 22, S4 touched the patient’s access needles and then touched the monitor and tubing multiple times, never performing hand hygiene or glove change. E. During an observation on 03/26/2025 at 11:55 AM of P1 in the treatment room at Station 22, S1 performed proper HH (hand hygiene) and applied gloves and touched the patient’s AV access, then proceeded to touch the monitor and tubing without changing gloves or hand hygiene. S1 touched the needles of the accessed AV site, then touched the tubing and monitor again. F. During an observation on 03/26/2025 at 12:00 PM of P1 in the treatment room at Station 22, S5, clinical, performed hand hygiene and applied gloves, did not turn off the blood pump, touched P1’s AV access and needles, and proceeded to touch the tubing and monitor without performing hand hygiene or glove change, then proceeded to touch P1’s AV access and needles again.”

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 51995 Based on observation and interview, the facility failed to ensure that expired materials were not available for patient use. This deficient practice could lead to infection in this immunocompromised (a condition where the immune system is not working properly, making it difficult to fight off infections) population. The findings are: A. During an observation on 03/24/2025 at 3:37 PM at the common supply area on the treatment floor revealed a 17g (grams) fistula needle (a catheter used to connect a hemodialysis patient to the machine) with an expiration date of 07/31/2024. B. During an interview on 03/24/2025 at 3:30 PM with S(Staff) 2, nonclinical, confirmed that the 17g fistula needle with an expiration date of 07/31/2024 was indeed expired. C. During an observation on 03/24/2025 at 3:45 PM in the supply storage area there were four of six containers of dialysate (a solution of salt, water, and electrolytes used during dialysis to help pull toxins from the blood) labeled “20K [Potassium - an electrolyte] 2.O Ca [Calcium - an electrolyte] Naturalyte” with an expiration date of 02/2025. D. During an interview on 03/04/2025 at 3:46 PM with S2 confirmed that the four containers of dialysate were expired.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 51995 Based on interview, observation, and record review, the facility failed to ensure AV access (a surgical connection made between an artery and vein to allow for better connection to hemodialysis machine was cleansed prior to treatment for 2 (P[patient]1 and P2) out of 2 (P1-P2) patients observed for proper accessing of a vascular access. This deficient practice could possibly result in or could lead to infection to the patient’s vascular access, which is critical to receiving this life sustaining treatment. A. Record review of the facility’s policy titled “Cannulation of Established Arteriovenous (AV) Fistula with Safety Needles, dated 08/07/2018, stated “Procedure 1. Wash hands. Put on PPE [personal protection equipment] 2. Have patient wash hands and access site with soap and water prior to entering the treatment area. If patient is unable to wash own access site, staff may do this at the chair-side.” B. During an observation on 03/26/2025 at 11:41 AM in the intake area P1 did not perform cleansing of the vascular access site. He walked directly to the treatment chair. S(Staff)4, clinical, did not verbally confirm whether the access site was washed and did not perform a wash prior to cleaning the site with antiseptic (solution that prevents the growth of infection causing organisms). C. During an interview on 03/26/2025 at 11:45 AM in the treatment room, P1 verbalized that the vascular access site was cleansed with alcohol pads at home but did not cleanse the vascular site upon arrival and prior to entering the treatment area. D. During an observation on 03/26/2025 at 12:10 PM in treatment room S6, clinical, accessed P2’s vascular access site. Patient did not wash his access prior to sitting in the treatment chair. Staff did not verbally confirm whether the access site was washed and did not perform a wash prior to cleaning the site with antiseptic. E. During an interview on 03/26/2025 at 12:30 PM with S6, clinical, confirmed that only an antiseptic was used on P2. S6 explained that extra cleansing was done to account for the site not being washed during the observation at 12:10 PM.”