Fmc - Dayton West

“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: 36303 Based on observation, interview and policy review, the facility failed to ensure staff wore eye protection when there was a potential for blood spatter/exposure. This had the potential to affect all the in-center hemodialysis patients. Findings include: 1. During an observation on 02/28/24 at 9:18 A.M. Registered Nurse (RN) E administered an intravenous (IV) medication to Patient #2. RN E accessed Patient #2’s dialysis needle tubing, attached medication syringe, unclamped needle tubing, administered the medication, removed the medication syringe, attached a syringe of normal saline (NS), and flushed the line. RN E was wearing a surgical face mask and prescription eyewear. RN E was not wearing eye protection with full side shields or a full-face shield. During an interview on 02/28/24 at 9:21 A.M., RN E confirmed that she was not wearing not wear eye protection with side shields or a face shield when accessing Patient #2’s hemodialysis lines to give a medication. During an interview on 02/28/24 at 9:30 A.M. the Administrator confirmed staff should wear eye protection when accessing a patients hemodialysis lines to administer medications. The Administrator confirmed there was a risk of blood splatter/exposure. 2. During an observation on 02/28/24 at 11:50 Patient Care Technician (PCT) C initiated Patient #5 dialysis treatment. PCT C inserted dialysis needles, connected dialysis tubing, and initiated Patient #5’s dialysis treatment. PCT C’s protective eyewear was resting on top of her head and not covering her eyes. PCT C’s surgical face mask was not covering her nose. 3. During an observation on 02/28/24 at 11:58 PCT C assessed Patient #6’s dialysis access due to a blood observed on the floor below her chair. PCT C removed blood soiled dressing and tape from Patient #6’s, repositioned dialysis needles, cleaned blood from Patient #6’s arm, her chair, and floor. PCT C’s protective eyewear was resting on top of her head and not covering her eyes. PCT C’s surgical face mask was not covering her nose. During an interview on 02/28/24 at 12:10 P.M. PCT C confirmed her protective eyewear was on top of her head and her surgical facemask was below her nose when she initiated Patient #5’s dialysis treatment and when she treated Patient #6’s dialysis access blood leak. PCT C confirmed she was ask risk for blood spatter/exposure during these procedures. Review of the facility’s policy titled “Personal Protective Equipment” dated 11/06/23 revealed personal protective equipment (PPE) including a full-face shield or mask and protective eyewear with full side shield, fluid resistant gowns, and gloves must be worn to protect employees from flood or other potentially infectious materials (OPIM). PPE is used to protect employees who are occupationally exposed to blood or OPIM when performing procedures which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Protective eyewear is provided by the facility and must be eye protection designed under normal conditions of use to prevent blood and OPIM form reaching the eyes. Prescription corrective eyewear is not considered eye protection.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 36303 Based on observation, interview and policy review, the facility failed to patients dialysis access were visible at all times during treatment and were assessed by staff. This affected Patient #4 and had the potential to affect all in-center hemodialysis patients. Findings include: Observation on 02/28/24 at 11:45 A.M. from revealed Patient #4’s dialysis access was not visible. Patient #4 was covered in a blanket and upper extremities were not visible. At 12:06 P.M. Staff C performed a safety check and entered information into Patient #4’s dialysis machine. Staff C did not uncover or assess Patient #4’s dialysis access. Patient #4 remained covered with a blanket and dialysis was not visible. Staff C then moved on to the next dialysis patient. During an interview on 02/28/24 at 12:10 P.M. Staff C confirmed that Patient #4’s dialysis access was not visible. Staff Confirmed she had not assessed Patient #4’s dialysis access when performing the safety check at 12:06 P.M. Staff C confirmed patient’s dialysis access should be visible at all times during treatment. Review of the facility’s policy titled “Patient Assessment and Monitoring” dated 05/01/23 revealed patient safety checks are completed eery 30 minutes. During safety checks staff will ensure connections are secure and visible, ensure access remains uncovered throughout the treatment, observe tape is secure and needles are intact, and there is no bleeding or infiltration noted.”