Usrc Herkimer Dialysis

“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: 46619 Based on document review, observation, and interview, in 2 of 2 observations, dialysis unit staff did not ensure patients performed hand hygiene post treatment before exiting the unit. This places patients and staff at risk for potential infection. Findings include: -- Review of the dialysis unit’s policy and procedure (P&P) titled “Infection Control and Precautions at the Dialysis Facilty,” revised 7/2025, indicated patients and visitors must perform hand hygiene before entering and leaving patient treatment area. -- Per observation on 12/9/2025 at 9:43 am, a patient left Station #2 post treatment and did not perform hand hygiene before exiting the dialysis unit. -- During interview of Staff A, Clinical Staff, on 12/9/2025 at 9:55 am, they acknowledged the above finding. -- Per observation on 12/9/2025 at 10:05 am, a patient left Station #1 post treatment and did not perform hand hygiene before exiting the dialysis unit. -- During interview of Staff B, Clinical Staff, on 12/9/2025 at 10:45 am, they acknowledged the above finding.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 46619 Based on document review, observation, and interview, 1) in 2 of 4 observations, facility staff did not clean and disinfect the patient scale between uses and the facility’s policy and procedure (P&P) did not address this. 2) In 1 of 2 observations, facility staff did not clean and disinfect the prime waste bucket between uses per the facility’s P&P. These lapses could place patients and staff at risk for potential exposure to infection. Findings related to 1) include: -- Per review of the facility’s P&P titled “Disinfection and Cleaning of Dialysis Machine Equipment,” revised 10/2025, it indicated to clean ancillary equipment with a 1:100 dilution of bleach solution. The P&P did not address cleaning and disinfecting of the scale. -- Per observation on 12/9/2025 at 9:45 am, a patient left Station #2 and held the side safety bar of the scale to steady themselves (balance) post treatment. The safety bars (side and front) of the scale were not wiped down (cleaned and disinfected) by staff after patient use. -- During interview of Staff A, Clinical Staff, they acknowledged the above finding at the time of observation. -- Per observation on 12/9/2025 at 9:55 am, a patient left Station #1 and held the side safety bar of the scale to steady themselves (balance) post treatment. The safety bars (side and front) of the scale were not wiped down (cleaned and disinfected) by staff after patient use. -- During interview of Staff B, Clinical Staff, on 12/9/2025 at 10:40 am, they acknowledged the above findings. Findings related to 2) include: -- Per review of the facility’s P&P titled “Disinfection and Cleaning of Dialysis Machine Equipment,” revised 10/2025, it indicated to disinfect all surfaces of the prime waste container, inside and out, with a moistened 1:100 bleach cloth. -- Per observation on 12/9/2025 at 10:05 am, staff cleaned and disinfected the dialysis station post treatment but did not clean and disinfect the internal and external surfaces of the prime waste bucket. -- During interview of Staff B, Clinical Staff, on 12/9/2025 at 10:45 am, they acknowledged the above findings.”

“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: 46619 Based on document review, observation, and interview, dialysis unit staff did not follow generally accepted standards of infection control. Specifically, in 1 of 1 observations, dialysis unit staff did not wash skin over the patient’s access site with soap and water or antibacterial scrub (or confirm that the patient did so) before proceeding with skin antisepsis prior to needle insertion. This could lead to infection. Findings include: -- Per review of the dialysis unit’s policy and procedure (P&P) titled “Assessment and Cannulation for AV Fistula/Graft and Patient Self Cannulation,” last revised 7/2025, patients must wash their access with soap and water prior to cannulation. If unable, staff should wash the patient’s access with soap and water, another approved cleansing agent, or a cleansing wipe. Staff will then further proceed to prepare the access site by disinfecting each access site. -- Per observation on 12/16/2025 at 10:00 am at Station #2, Staff A, Clinical Staff, did not wash skin over the patient’s access site with soap and water or antibacterial scrub (or confirm that the patient did so) before proceeding with skin antisepsis prior to needle insertion. Staff A acknowledged this finding at the time of observation.”