Davita Ridge Park 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 observation, interview and policy review, the facility failed to ensure staff changed gloves and sanitized hands when going between clean and dirty areas. This had the potential to affect all patients and staff. The census was 47. Findings include: During an observation on 05/08/24 at 9:37 AM, Staff T was in station five wearing gloves. Staff T hung a bag of normal saline and touched the dialysis machine. Without changing gloves or sanitizing hands, Staff T disconnected the patient’s blood line from a central venous catheter and attached a syringe of Heparin. On 05/09/24 at 12:29 PM Staff A was made aware of these findings. Review of the policy titled “Infection Control for Dialysis Facilities”, revised April 2023, revealed 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.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 29732 Based on observation, interview and policy review, the facility failed to ensure non-disposable equipment were disinfected after each patient’s use. This had the potential to affect all patients and staff. The census was 47. Findings include: 1. On 05/08/24 at 9:17 AM, Staff R was observed to use a stethoscope on the patient in station 11 and went back to the nursing station. Without sanitizing the stethoscope, Staff R went to station one at 9:45 AM and used the stethoscope on another patient. 2. On 05/08/24 at 9:18 AM, Staff F was observed to use the thermometer on the patient in station five and put it back on the clean supply table without sanitizing it. 3. On 05/08/24 at 9:42 AM, Staff T took a patient’s temperature in the lobby then put it back on the clean supply table without sanitizing it. 4. On 05/08/24 at 9:43 AM, Staff F was observed to use the thermometer on the patient in station one then put it back on the clean supply table without sanitizing it. 5. On 05/08/24 at 9:55 AM, Staff E was observed to use the thermometer on the patient in station 11 then put it back on the clean supply table without sanitizing it. 6. On 05/09/24 at 10:19 AM, Staff D was observed to use the thermometer on the patient in station 10 put it back on the clean supply table without sanitizing it. 7. On 05/09/24 at 10:40 AM, Staff D was observed to use the thermometer on the patient in station 9 then put it back on the clean supply table without sanitizing it. On 05/09/24 at 12:29 PM, Staff A was made aware of these findings. During an interview on 05/09/24 at 12:37 PM, Staff U confirmed the thermometer does need to be cleaned between patients. Review of agency policy titled “Infection Control for Dialysis Facilities”, revised April 2023, revealed non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station. Stethoscopes will be disinfected with an alcohol prep pad.”