322548 - Liberty Rio Rancho (Fmc)

“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: 50656 Based on observations, staff interview and record review, the facility failed to ensure adherence to infection control practices when a staff member did not perform hand hygiene and change gloves after touching a dialysis machine then cannulating (inserting a dialysis needle into the patient’s fistula) a patient’s fistula (a surgically created connection between a vein and an artery, usually in the arm which allows for easier access for a large amount of blood flow for receiving dialysis treatment) to begin hemodialysis [a medical procedure that filters and cleans the blood when the kidney can no longer do so] treatment for 1(P(patient) 7) of 16 (P5, P6, P8, P9, P18, P19, P29, P30, P31, P32, P33, P34, P35, P36, P37, and P38) patients receiving hemodialysis. This deficient practice could likely lead to the increased risk of bloodstream infections [an infection where harmful germs enter the blood, possibly causing serious illness or death] and cross contamination (the process where bacteria or other microorganisms are unintentionally transferred from one object to another, with harmful effects) which may cause complications leading to poor patient health outcomes for all patient receiving hemodialysis treatment at the facility. The findings are: A. During an observation on 02/18/25 at 9:35 am in the facility HD treatment room, S(staff)11, clinical, touched a HD machine computer screen with exam gloves on then without removing the contaminated gloves and without performing hand hygiene, S11 cleaned P7’s fistula site then cannulate the patient’s fistula to begin HD treatment. B. During an interview on 02/18/25 at 9:41 am with S11, clinical, S11 was asked what the facility policy is for hand hygiene prior to cannulating a patient’s fistula for HD treatment, S11 replied “ I’m supposed to wash my hands. Oh, sorry I didn’t do that.” C. Record review of the facility’s policy titled “Hand Hygiene,” dated 11/06/2023 revealed the following: 1. Purpose: The purpose of this policy is to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination [the transfer of harmful bacteria from one person, object or place to another]. 2. Responsibility: All staff, patient care givers, including physicians and non-physician practioners, social workers, dieticians, and any other indirect patient care staff must follow the same requirements for and hygiene. 3. Hand hygiene includes either washing hands with soap and water or using a waterless alcohol-based antiseptic hand rub with 60-90% alcohol content. Drying effects of alcohol can be counteracted by addition of emollient or humectants, e.g. 1-3% glycerol. - Hands will be Decontaminated [sic] using alcohol-based hand rub or by washing hands with antimicrobial soap and water. -Before and after direct contact with patients. -Before performing any invasive procedure such as vascular access cannulation or administration of parenteral medications [medications or fluids given directly into the bloodstream though a needle]. -After contact with inanimate objects near the patient. 4. Procedure for Decontaminating Hands with Alcohol Based Hand Rubs: Follow the procedure outlined below when decontaminating hands with alcohol-based hand rubs: Step a. If gloves are worn, remove and discard gloves in an appropriate waste container. Exposes the skin for decontamination [sic]. b. Apply alcohol-based hand rub to the palm of one hand using the amount recommended by the product manufacturer. Adequate amount of product must be used for maximum effectiveness. c. Rub hands together covering all surfaces of the hands and fingers, until hands are dry. -Allowing alcohol to dry completely allows adequate contact time to kill germs, allows alcohol to evaporate, and prevents risk of igniting flames due to alcohol’s flammable properties.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 50656 Based on observations, record reviews and staff interviews, the facility failed to ensure that the arterial drip chambers [small, transparent container that holds blood coming from the patient’s artery before it is filtered by the dialysis machine] were filled to the required level of 85% to 95% full for all patients during hemodialysis treatments for 3 (P[patients]1, P2, and P3) of 21 (P1, P2, P3, P23, P25, P57, P58, P59, P60, P61, P62, P63, P64, P65, P66, P67, P68, P69, P70, P71, and P72 ) patients receiving hemodialysis treatments. This deficient practice could lead to the risk of air embolism, [a condition where air bubbles enter the bloodstream, and may cause serious health issues like heart of brain damage] blood clotting, and inefficient blood flow which can compromise patient safety and dialysis effectiveness for all patients receiving hemodialysis treatments at the facility. The findings are: A. During an observation on 02/17/25 at 1:37 pm, arterial drip chamber for P1 was filled below 75% full, below the required fill level of between 85% to 95% full per facility policy. B. During an observation on 02/17/25 at 1:37 pm, arterial drip chamber for P2 was filled below 75% full, below the required fill level of between 85% to 95% full per facility policy. C. During an observation on 02/17/25 at 1:37 pm, arterial drip chamber for P3 was filled below 75% full, below the required fill level of between 85% to 95% full per facility policy. D. During an interview on 02/17/25 at 1:41 pm with S(staff)1, clinical, when asked what the facility’s policy and procedure was for minimum arterial drip chamber fill level, S1 replied “They have to be 3/4th full (75% full).” When S1 was asked if the drip chamber for P1 was at the require level of 3/4ths full, S1 responded “No.” E. During an interview on 02/17/25 at 1:41 pm with S1, clinical, when asked what the facility’s policy and procedure was for minimum arterial drip chamber line, S1 replied “They have to be 3/4ths full (75% full).” When S1 was asked if the drip chamber for P2 was at the require level of 3/4ths full, S1 responded “No.” F. During an interview on 02/17/2025 at 1:47 pm with S1, clinical, when asked what the facility’s policy and procedure was for minimum arterial drip chamber line, S1 replied “They have to be 3/4ths full (75% full) .” When S1 was asked if the drip chamber for P3 was at the require level of 3/4ths full, S1 responded “No.” G. Record review of the facility’s policy titled “Initiation of Treatment Using an Arteriovenous Graft [a surgically created connection between an artery and a vein, used in dialysis to make it easier to access the bloodstream for treatment] or Fistula [a surgically created connection between an artery and a vein to to make receiving dialysis easier]and Optiflux Single Use Ebeam Dialyzer [a type filter that works as an artificial kidney used in dialysis treatments]” on page 5 of 7, dated 05/06/2024 revealed the following: Prior to starting the blood pump, verify the following: 1. All connections are secure 2. Dialysate lines are attached properly to the dialyzer. 3. There is at least 300 mL [a unit of volume primarily used to measure liquid] of saline in the saline bag and the saline line is double clamped. 4. Any unused administration lines are clamped. 5. The arterial chamber is 85 - 95% full.....”