Fmc - Clayton Taylor

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 33020 Based on record review, interviews, observations, mock audit review, and policy review, the facility failed to use appropriate Personal Protective Equipment (PPE) while providing End Stage Renal Dialysis (ESRD) treatment for one of four sampled patient’s who were identified to require isolation precautions. This had the potential to affect all patients who receive ESRD treatment at this facility. The census was 62. Findings include: On 05/22/24 at 9:15 A.M., an interview with Staff A, Staff C, and Staff E, during an entrance conference, revealed an audit was recently conducted because there had been some rumored issues concerning staff not using appropriate PPE while providing ESRD for isolation patients in the facility. Further interviews during the entrance conference revealed there were no concerns identified during the audit related to staff not using appropriate Personal Protective Equipment (PPE) while providing patient care for Hepatitis B patients being dialyzed in the isolation area, but even though no concerns were observed related to isolation PPE usage “there have been rumors” and “we are watching.” On 05/22/24 at 9:49 A.M., an interview with Staff E revealed that Staff D and Staff G have been observed while providing ESRD for isolation patients, and they do not always appear to wear appropriate PPE while providing care and services in the Hepatitis B isolation room, but the leadership staff may have addressed that issue with the staff members involved. On 05/22/24 at 1:38 P.M., observation of Staff G providing dialysis care for Patient (Pt) 1 revealed Staff G was providing dialysis services in the isolation treatment room for Pt 1 while only wearing gloves and a mask and the gloves and mask were removed while Staff G was still in the isolation room providing care for Pt 1. No gown was observed being used at all. An observation was made with Staff A present to confirm the observation, and it was confirmed that Staff G should not be in the isolation room with Pt 1 without appropriate PPE because Pt 1 was a Hepatitis B positive patient. Further observation revealed Staff G stayed in the area near the isolation room and Staff G was not observed to be providing ESRD care for other patients in the facility. On 05/22/24 at 1:48 P.M. an interview with Staff J confirmed the patient in the isolation room was Pt 1 and confirmed Pt 1 was a Hepatitis B positive patient. Further interview with Staff J revealed all staff should be wearing full PPE including gowns, gloves, and masks while they are providing care for isolation patients. An interview with Staff J and an observation outside the isolation room confirmed signage with instructions for the staff to use appropriate PPE was posted. On 05/23/24 at 9:01 A.M. a review of the Hepatitis B isolation policy revealed all patients that sit near the isolation room are immune, and staff have no contact with susceptible patients. All patients that are Hepatitis B positive must receive dialysis under isolation precautions. Further review revealed hand hygiene must be practiced when entering and leaving the isolation area. Anyone entering the isolation area/room during the patient’s treatment must wear a separate fluid resistant gown at all times. Personal Protective Equipment (PPE) must be removed and discarded or left in the isolation room area if not soiled. On 05/23/24 at 10:00 A.M. a review of the Mock Survey Review Audit revealed issues related to educating staff concerning appropriate PPE usage and infection control, appropriate monitoring of vital signs, equipment preparation, and dressing changes were discussed in the audit plan that was completed recently. This is an example of non-compliance found under Complaint Number OH00153339.”