Fmc Southern Westchester Dialysis Ctr

“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, the facility failed to ensure patients washed or sanitized hands after holding access sites (A vascular access is created so that blood can be drawn from the body and run through a dialysis machine, where excess fluid and toxins are removed from the blood. (i) The filtered blood then flows back through the access into the body) for one of three survey days. The failure for patients to wash or sanitize hands after holding access site had the potential for cross contamination and could affect 99 in-center patients. Findings include: Observation on 06/25/24 at 10:30 AM revealed Patient (P) 8 at Station 2 applied pressure to the left lower arm access site until bleeding had stopped. When finished the patient walked to the scale with the glove still on his/her hand. Patient Care Technician (PCT) 3 assisted the patient to the scale to retrieve his/her weight and removed the glove from the patient after the patient retrieved the weight and pushed the buttons on the scale. The patient did not wash or sanitize hands and PCT 3 did not instruct or encourage the patient to wash or sanitize hands. During an interview on 06/25/24 at 10:40 AM PCT 3 acknowledged P8 did not wash or sanitize hands after holding access site and he/she did not instruct or encourage the patient to prevent cross contamination. During an interview on 06/26/24 at 10:45 AM the Charge Nurse stated patients should wash or sanitize hands after holding access sites at the end of treatment to prevent cross contamination of blood borne pathogens. Review of the facility’s policy titled, “Hand Hygiene.” Revised 11/06/2023 indicated the following: “ ...Patients should perform hand hygiene if able, prior to and after each dialysis treatment ...To help ensure the prevention of cross contamination to their family members or other patients, hand hygiene must be performed ...””

“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, the facility failed to ensure a patient wore a mask that was covering his/her nose during initiation and discontinuation of dialysis via a Central Venous Catheter (CVC) (thin, flexible tube is inserted into a vein, usually below the collarbone. It is guided (threaded) into a large vein above the right side of the heart) for two of three observations. The failure to ensure the mask was covering the nose as required in policy, had the potential for contamination of the CVC and had the potential for increased the risk of infections, and could affect 20 of 99 patients that have CVCs in the facility. Findings include: 1. During an observation on 06/24/24 at 3:50 PM, Registered Nurse (RN) 1 was at Station 27 discontinuing the treatment via a CVC. RN1 completed CVC discontinuation of the dialysis treatment via the CVC, however, the patient’s mask remained below his/her nose the entire time. During an interview on 06/24/24 at 4:00 PM RN 1 confirmed the patient’s mask was not covering his/her nose as required to prevent contamination. 2. During an observation on 06/25/24 at 12:10 PM Licensed Practical Nurse (LPN) 1 was at Station 12 discontinuing the treatment via a CVC. LPN 1 completed CVC discontinuation of the dialysis treatment via the CVC, however, the patient’s mask remained below his/her nose the entire time. During an interview on 06/25/24 at 12:20 PM LPN 1 confirmed the patient’s mask was not covering his/her nose as required to prevent contamination. During an interview on 06/26/24 at 10:45 AM the Charge Nurse stated the mask should be covering the patients’ mouth and nose to prevent cross contamination of the CVC. Review of the facility’s policy “Termination of Treatment Using a Central Venous Catheter and Optiflux Ebeam Single Use Dialyzer,” revised 05/06/24, indicated, “ ...place mask on patient, perform hand hygiene then don new gloves ...” Review of the facility’s policy “Initiation of Treatment Using a Central Venous Catheter and Optiflux Ebeam Single Use Dialyzer,” revised 05/06/24, indicated, “ ...place mask on patient, perform hand hygiene then don new gloves ...””

“MICROB MONITOR-MO DIALYS SAMPLE/COLLECT/FREQ CFR(s): 494.40(a) 7.2 Microbial monitoring methods: 7.2.1 General: Dialysate: monthly dialysate sample/collection/freq Culture ...dialysate fluid weekly for new systems until a pattern has been established. For established systems, culture monthly unless a greater frequency is dictated by historical data at a given institution. Dialysate samples should be collected from at least two machines monthly and from enough machines so that each machine is tested at least once per year. If testing of any dialysis machine reveals a level of contamination above the action level, an investigation should be conducted that includes retesting the offending machine, reviewing compliance with disinfection and sampling procedures, and evaluating microbiological data for the previous 3 months to look for trends. The medical director also should be notified. An example of a decision tree for this process is given in Figure 1. 7.2.2 Sample collection Dialysate samples should be collected from a dialysate port of the dialyzer ... [or] dialysate sampling ports that can be accessed using a syringe. At least 25 mL of fluid, or the volume specified by the laboratory performing the test, should be collected in sterile endotoxin-free specimen containers. This Standard is not met as evidenced by: 28297 Based on interview, facility document review, and facility policy review, the facility failed to ensure 15 of 34 hemodialysis machines were tested for water cultures within 365 days as required. The failure to complete water cultures as required had the potential for bacteria growth to not be detected in a timely manner that could affect 99 in-center patients. Findings include: Review of the “water and dialysate cultures” (The source of water used in hemodialysis consists basically of drinking water, purified by various techniques, whose composition and quality depend on its origin. The quality of the water can change from season to season or even day to day. Monitoring of the quality of water used for dialysis is a vital aspect of hemodialysis treatment. Water cultures are completed to ensure there are no growth of microbiology count or endotoxins) provided by the facility from 06/01/22-06/25/24 revealed the following: 1. Hemodialysis machine 4 colony count, and endotoxins were completed on 01/09/23 and not again until 02/05/24, 26 days late. 2. Hemodialysis machine 5 colony count, and endotoxins were completed on 01/09/23 and not again until 02/05/24, 26 days late. 3. Hemodialysis machine 6 colony count, and endotoxins were completed on 01/09/23 and not again until 02/05/24, 26 days late. 4. Hemodialysis machine 7 colony count, and endotoxins were completed on 02/03/23 and not again until 03/04/24, 31 days late. 5. Hemodialysis machine 8 colony count, and endotoxins were completed on 02/03/23 and not again until 03/04/24, 31 days late. 6. Hemodialysis machine 9 colony count, and endotoxins were completed on 02/03/23 and not again until 03/04/24, 31 days late. 7. Hemodialysis machine 10 colony count, and endotoxins were completed on 03/03/23 and not again until 04/01/24, 30 days late. 8. Hemodialysis machine 11 colony count, and endotoxins were completed on 03/03/23 and not again until 04/01/24, 30 days late. 9. Hemodialysis machine 12 colony count, and endotoxins were completed on 03/03/23 and not again until 04/01/24, 30 days late. 10. Hemodialysis machine 13 colony count, and endotoxins were completed on 04/03/23 and not again until 05/10/24, 37 days late. 11. Hemodialysis machine 14 colony count, and endotoxins were completed on 04/03/23 and not again until 05/10/24, 37 days late. 12. Hemodialysis machine 15 colony count, and endotoxins were completed on 04/03/23 and not again until 05/10/24, 37 days late. 13. Hemodialysis machine 16 colony count, and endotoxins were completed on 05/08/23 and not again until 06/07/24, 29 days late. 14. Hemodialysis machine 17 colony count, and endotoxins were completed on 05/08/23 and not again until 06/07/24, 29 days late. 15. Hemodialysis machine 18 colony count, and endotoxins were completed on 05/08/23 and not again until 06/07/24, 30 days late. During an interview with the Biomedical Technician revealed he/she completed the water cultures according to the schedule however did not keep up with the dates between the testing and did not know that machines were late with water testing. During an interview with the covering Area Technical Operations Manager (ATOM) revealed the facility changed the culture testing for machines from every 6 months to annually in October of 2023. The ATOM stated they had identified they were behind on the water cultures but had not put anything into place to get caught up on the water cultures as of the survey day. Review of the facility’s policy “Microbiology Monitoring of Dialysate,” revised 09/07/16 indicated the following: “ ...The purpose of this policy is to define the minimum monitoring requirements of microbiological contaminant levels of dialysate ...After successful baseline sampling, microbiological samples will be collected as follows: Incenter - A minimum of two machines per month and enough machines so all machines, including backup equipment, are tested at a minimum of once a year ...””