322558-Albuquerque Southwest Mesa

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 47302 Based on record review, interview and observation the facility failed to meet the Condition for Coverage to ensure patients are protected from exposure to infectious pathogens (organisms that can lead to illness) to the bloodstream which can cause serious infection. This deficient practice could lead to serious illness and poor patient outcomes. The findings are: A. The facility failed to ensure staff washed their hands and changed gloves prior to an intravenous (given through the veins) medication administration for all patients receiving hemodialysis (blood cleansing treatment for kidney failure). Refer to tag V113. B. The facility failed to ensure staff followed the facility’s policy for central venous catheter (CVC, long tube inserted through a vein for hemodialysis, cleaning of the blood) dressing changes. Refer to tag V147. 50656”

“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: 47302 Based on record review, observation, and interview the facility failed to ensure staff washed their hands and changed their gloves prior to an intravenous (IV, given through the veins) medication administration for all patients receiving hemodialysis (blood cleansing treatment for kidney failure). This deficient practice could lead to an introduction of infectious pathogens (organisms that can lead to illness) to the bloodstream which can cause serious infection. The findings are: A. Record review of facility’s policy titled, “Hand Hygiene” dated 03/16/2022 on page 1 it stated, “Purpose: To prevent the transmission of infectious pathogens through cross contamination by the patient caregiver. Supportive Data: Hand hygiene is the most vital factor in preventing cross-contamination [sic] or cross-infection between patients and/or personnel. Hands and other skin surfaces should be washed immediately and thoroughly if contaminated with blood and other body fluid or potentially contaminated surfaces. The transmission of infectious agents without thorough hand hygiene has been well documented. Hand hygiene is defined as hand washing with soap and water or use of a 60- 90% alcohol-based hand sanitizer. Policy: All patient care personnel will be responsible for hand hygiene. Hand hygiene is done: . . . 3. After touching blood, body fluids, secretions, excretions, [bodily fluids] and potentially contaminated items. 4. Before and after direct contact with patients. 5. Before and after performing invasive procedures such as Cannulation [process of accessing fistula] or medication administration. 6. Immediately after gloves are removed. 7. After contact with medical equipment and environmental surfaces such as the machine. 8. When entering or exiting the treatment area. . .” B. During an observation on 06/26/2024 at 8:14 AM S (staff) 4, clinical staff member prepped medications in the medication room. S4 exited the medication room wearing gloves, entered treatment room, approached P (patient) 9 and administered IV medication through patient’s fistula (surgically created connection between an artery and vein that provides access point for hemodialysis). S4 did not remove gloves or perform hand hygiene prior to medication administration or after contact with environmental surfaces. C. During an observation on 06/26/2024 at 08:26 AM S3, clinical staff wore exam gloves while drawing up intravenous (medication given directly into the blood stream through a vein or an artery) then opened a closed door from the medication room to the dialysis treatment room by grasping the door handle with gloved hands. S3 then approached P12 and without changing gloves or performing hand hygiene, cleaned the medication administration port with an alcohol wipe, administered the medication into the patient. S3 then disposed of the empty syringe in a sharps container and removed exam gloves and performed hand hygiene. D. During an observation on 06/26/2024 at 8:33 AM S4, clinical staff member opened the door to the medication room, with medication in gloved hand and administered medications to an unidentified patient receiving dialysis. S4 did not remove gloves or perform hand hygiene prior to medication administration or after contact with environmental surfaces. E. During an interview on 06/26/2024 at 4:00 PM with S2, clinical supervisor it was explained that because the staff are putting on clean gloves and then prepping medication for immediate administration, they do not have to perform hand hygiene or replace gloves between the medication room and administration. 50656”

“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: 47302 Based on record review and observation the facility failed to ensure staff followed the facility’s policy for central venous catheter (CVC, long tube inserted through a vein for hemodialysis, cleaning of the blood) dressing change for 3 (P [patients] 13, P14, P15) out of 3 patients (P13-P15) observed for CVC site care. This deficient practice could lead to an introduction of infectious pathogens (organisms that can lead to illness) to the bloodstream which can cause serious infection. The findings are: A. Record review of facility’s policy titled, “Central Venous Catheter (CVC) Exit Site Disinfection and Dressing Change” dated 12/20/2018 under “Supportive Date” stated “Vascular access is essential to hemodialysis therapy. Positive patient outcomes are dependent on complication-free vascular access. The use of central venous catheters (CVCs) can be an essential means of providing urgent, and in some cases, long term vascular access. Aseptic [clean] technique and prevention and early treatment of CVC-related complications may greatly reduce associated morbidity (illness), hospitalizations, and mortality (death) in the CVC hemodialysis patient. The use of central venous catheters for hemodialysis is the most common factor contributing to bacteremia [bloodstream infection] in patients on dialysis, and the relative risk for bacteremia in patients with dialysis catheters is seven times the risk for patients with primary arteriovenous fistulas [surgically created connection between an artery and vein that provides access point for hemodialysis]. . . Due to the increasing microbial resistance [bacteria that is not affected by medications intended to treat them] to mainstream [commonly used] antibiotics, infection prevention must be considered the first rule of vascular access maintenance.” On page 4 in procedure table stated, “6. With clean-gloved hands, remove old dressing. Examine the old dressing for blood, drainage, dryness, odor and integrity [whether dressing is intact]. Discard old dressing. Perform hand hygiene. Don [put on] clean gloves. . . . Evaluate CVC exit-site and tunnel [where catheter is entering the body through the vein] for any abnormal findings. . . Remove gloves and discard. Perform hand hygiene. Don new gloves. Clean exit site. . . Once dry, place a sterile [equipment that has been completely cleaned of all infectious pathogens] folded 2 x 2 [2 inches by 2 inches] under catheter at site of insertion, and place an additional open sterile 2 x 2 gauze pad directly over exit site. Secure gauze with tape on all four sides of gauze, or place non-occlusive [breathable] transparent dressing over gauze, ensuring all edges are sealed. . . .Remove gloves and perform hand hygiene.” B. During an observation on 06/26/2024 at 12:49 PM, Staff (S)4, clinical staff member performed CVC dressing changes on P13. S4 performed hand hygiene, put on gloves, removed old dressing, cleansed the CVC insertion site, allowed site to dry, removed gloves, performed hand hygiene, put on new gloves and placed new, non-occlusive dressing over CVC. S4 did not perform hand hygiene between removal of the old dressing, cleansing the CVC site and putting a new sterile dressing. C. During an observation on 06/26/2024 at 1:31 PM, S4, clinical staff member performed CVC dressing changes on P14. S4 performed hand hygiene, put on gloves, removed old dressing, cleansed the CVC insertion site, allowed site to dry, removed gloves, performed hand hygiene, put on new gloves and placed new, non-occlusive dressing over CVC. S4 did not perform hand hygiene between removal of the old dressing, cleansing the CVC site and putting a new sterile dressing. D. During an observation on 06/26/2024 at 1:45 PM, S4, clinical staff member performed CVC dressing changes on P15. S4 performed hand hygiene, put on gloves, removed old dressing, cleansed the CVC insertion site, allowed site to dry, removed gloves, performed hand hygiene, put on new gloves and placed new, non-occlusive dressing over CVC. S4 did not perform hand hygiene between removal of the old dressing, cleansing the CVC site and putting a new sterile dressing. 50656”