Davita Grove City 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: 29732 Based on observations, policy review, and staff interview, the facility failed to ensure staff wore gloves when touching equipment, changed gloves when leaving stations, and performed hand hygiene after glove removal. This occurred with three out of three staff observed. (Staff A, B and C) The census was 24. Findings include: Observations made on 09/05/24 from 10:10 AM to 11:19 AM included: 1. At 10:16 AM Staff C was observed to touch the machine at Station 4 then went to get clean supplies wearing the same gloves. At 10:18 AM Staff C was observed to touch the machine in Station 4, took the gloves off, and put new gloves on without using hand sanitizer. At 10:22 Staff C was observed to touch the machine in Station 2 then touched the machine in Station 4 without changing gloves. At 10:25 AM Staff C was observed to touch the machine in Station 2 then go get clean supplies without changing gloves and performing hand hygiene. 2. At 10:32 AM Staff B was observed to touch the patient belongings and blood pressure cuff in Station 5 then go and touch the machine in Station 7 without changing gloves. 3. At 10:43 AM Staff A was observed to change the dressing after the needles had been removed in Station 4 then removed the gloves without performing hand hygiene afterwards. At 11:02 AM Staff A was observed to touch the machine in Station 4 with no gloves on. Review of the facility policy titled “Infection Control for Dialysis Facilities,” revised 04/2023, revealed all staff will perform hand hygiene prior to gloving and immediately after removal of gloves, after contamination with blood or other infectious material, after patient and dialysis delivery system contact, between patients even if the contact is casual, and before touching clean areas such as supplies and supply cart. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station. Gloves should be changed when going from a “dirty” area or task to a “clean” area or task and after touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient’s dialysis delivery system. Interview on 09/05/24 at 1:57 PM Staff A was made aware of these findings.”

“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 observations and policy review, the facility failed to ensure proper personal protective equipment (PPE) was used. This occurrred with two out of three staff observed. (Staff A and C) The census was 24. Findings include: Observations on 09/05/24 from 10:10 AM to 11:19 AM revealed at 10:11 AM Staff C was observed to pull needles in Station 1with no face mask or goggles in use. At 10:28 AM Staff A was observed to flush the venous line on the patient in Station 4 without a mask on. At 10:43 AM Staff A was observed to change the dressing after needles had been removed in Station 4 with no face mask on. Review of the facility policy titled “Infection Control for Dialysis Facilities,” revised 04/2023, revealed appropriate PPE (gown, gloves, eye protection, face shield) will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces, for example, patient care areas.”