Rotterdam-Schenectady Dialysis Center

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 20205 Based on observation, interview and document review, while observing hemodialysis care and infection control practices in the medication preparation area, the surveyor observed one open multidose vial of heparin in the medicine cabinet. The open vial was not dated/timed or initialed to indicate who opened the bottle and when. Findings include: -Department of health survey staff were observing medication pass on 1/30/2024. On 1/30/24 at 11:30 AM while in the medication prep area the surveyor observed one multi dose bottle of heparin in the medicine cabinet that was opened with no date or initials of the person who opened the bottle. -The observation was confirmed with staff “F” and she discarded the bottle in the trash. -Review of facility policy G48 “Medications handling, Administration, Storage and Disposal” (revision 6/2023) indicates that multi dose medication vials can be used for up to 28 days after initial entry, as long as the vial is handled aseptically and stored per manufacturer instructions according to the package insert. Multi dose medication vials shall be labeled with the date the vial is first entered and the initials of the person who first entered the vial.”

“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: 42925 Based on observation, interview and document review, dialysis unit staff did not follow generally accepted standards of infection control. Specifically, in 1 of 18 observations, open supplies to be used for discontinuation of dialysis were left on a chair table. This could lead to infection. Findings includes: -On 1/31/2024, during observation of patients undergoing dialysis (between 9:30 am-10:15 am) it was noted post dialysis supplies were on a chair table for patient in Chair #10. The supplies identified were open 4 x 4’ s’, 2 rolls of tape, a Band-Aid and an underpad. -Staff “C” stated on interview, that Staff “H” had left these materials on the chair table in preparation for when the dialysis was to be discontinued. She said staff “H” is new and this is not the facility’s routine practice. Staff “C” stated supplies are usually brought to the patient’s chair when discontinuation of dialysis is about to occur. Leaving the gauze pads open to the air increases the potential for dust and airborne contaminants to compromise the sterility of the supplies. The pads were let unattended for forty five minutes leaving the cleanliness of the pads questionable. -These findings were reported to Staff “C” on 1/31/2024 at 10:15 am and Staff “A” at 10:30 am and again at the exit conference on 2/2/2024 at 1:00 PM with Staff “A”. -Department of Health review of the dialysis unit’s policy and procedure titled “Closed System Treatment Termination (Non-Reuse) -AV Fistula and AV Graft” last revised 7/19/2015 was completed on 2/5/2024. The policy lacked a provision for keeping sterile supplies wrapped until time of use.”