Fmc - Wayne County Kidney Center

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 29732 Based on observation, policy review and staff interview, the facility failed to ensure staff wore gowns to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur for two of three staff observed during the survey (Staff X and Staff R). The census was 78. Findings include: Review of the facility policy titled, “Personal Protective Equipment” effective 02/14/18, revealed disposable gloves must be used when touching any part of the dialysis machine or equipment at the dialysis station. Change gloves and do hand hygiene between each patient and/or station to prevent cross-contamination. Fluid resistant gowns will be worn to protect staff from blood or other potentially infectious materials to pass through to reach the staff’s skin or clothes. An onsite visit was made to Smithfield Western Springer Health Care facility on 11/02/23 to observe dialysis care provided at the facility. At 8:20 AM Staff X was observed to chart vital signs on a clip board, which was located on top of the dialysis machine, during the dialysis treatment at station 6 without gloves on and gown untied and at mid chest level. At 8:44 AM Staff R was observed to chart vital signs on a clip board, which was located on top of the dialysis machine, during the dialysis treatment at station 1 without gloves on. Interview on 11/02/23 at 8:45 AM with Staff R revealed they were not aware that gloves were needed to document vital signs on a clip board which was located on top of the dialysis machine during the dialysis treatment. At 8:55 AM Staff X was observed to touch the dialysis machine at station 6 without gloves on and gown untied and at mid chest level. Interview on 11/02/23 at 8:56 AM with Staff X confirmed gloves were not worn and their gown was untied and down over their shoulders. At 8:57 AM Staff X was observed to chart vital signs on a clip board, which was located on top of the dialysis machine, during the dialysis treatment at station 3 with their gown untied and at mid chest level. At 9:01 AM Staff X was observed touching the dialysis machine at station 6 with their gown untied and at mid chest level.”

“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: 29732 Based on observation, policy review, and staff interview, the facility failed to implement cleaning and disinfection of contaminated medical devices and equipment for two of two Registered Nurses (RN) observed providing treatment (Staff S and Staff X). The census was 78. Findings include: Review of facility policy titled, “Cleaning and Disinfecting the Dialysis Station,” effective 09/05/23, revealed the dialysis station could become contaminated with blood and other body fluids during treatment. After use, any non-disposable equipment and supplies brought into the dialysis station (example: stethoscope) must be disinfected before being removed from the dialysis station. An onsite visit was made to Smithfield Western Springer Health Care facility on 11/02/23 to observe dialysis services provided at the facility. At 8:30 AM Staff S was observed to use a stethoscope on the patient in station 2 and at 9:17 AM was observed to use the stethoscope on the patient in station 5. Staff S did not disinfect the stethoscope between patients. Interview on 11/02/23 at 9:20 AM with Staff S confirmed this finding. At 8:40 AM Staff X was observed to use a stethoscope on the patient in station 3 and at 8:58 AM was observed to use the stethoscope on the patient in station 4. Staff X did not disinfect the stethoscope between patients. Interview on 11/02/23 at 9:15 AM with Staff X confirmed this finding.”