Fresenius Kidney Care Marymount

“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 failed to ensure staff followed universal precautions related to glove use and hand hygiene. This could potentially affect all patients and staff. The census was 19. Findings include: 1. During an observation on 11/04/24 at 5:42 AM, Staff A, B and C were observed in the treatment room setting up dialysis machines. Staff A, B and C were not wearing gloves. 2. During an observation on 11/04/24 at 6:15 AM, Staff C touched the dialysis machine at station 9 without gloves on while a patient was receiving treatment on the machine. 3. During observations on 11/04/24 at 6:08 AM, 6:16 AM, 6:41 AM, 6:47 AM, 6:52 AM and 7:04 AM, Staff B was took off soiled gloves, and without performing hand hygiene, put on new gloves. 4. During an observation on 11/04/24 at 6:48 AM, Staff A worked on the dialysis machine in station 14. Staff A removed gloves, and without performing hand hygiene, went to the nursing station. 5. During an observation on 11/04/24 at 11:36 AM, Staff C took off gloves and performed hand hygiene. Without donning new gloves, Staff C reclined a patient’s chair. Without performing hand hygiene, Staff C put on clean gloves, then went to assist another patient. During an interview ant the time of the observation, Staff C confirmed this finding. During an interview on 11/04/24 at 8:42 AM, the Facility Manager was made aware of these findings. Review of the facility’s policy titled “Hand Hygiene”, effective 06/11/23, revealed decontamination of hands by using alcohol-based hand rub or by washing hands with antimicrobial soap and water immediately after removing gloves. Review of the facility’s policy titled “Exposure Categories and Determination”, effective 07/01/24, revealed gloves are to be worn when touching any part of the dialysis machine or equipment while the patient is on dialysis and when setting up the machine.”

“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 staff disinfected multi-patient use equipment between patient use. This could potentially affect all patients and staff. The census was 19. Findings include: 1. During an observation on 11/04/24 at 6:16 AM, Staff B was wearing a thermometer around the neck. Staff B used the thermometer on the patient in station 14. At 6:39 AM, the thermometer was used on the patient in station 12 and at 7:03 AM on the patient in station 16. Staff B did not sanitize the thermometer between patients. 2. During an observation on 11/04/24 at 6:46 AM, Staff A used the stethoscope on the patient in station 13. Without sanitizing the stethoscope, Staff A used the stethoscope on the patient in station 14. During an interview on 11/04/24 at 8:42 AM, the Facility Manager was made aware of these findings. Review of the facility’s 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 (ex. stethoscope and thermometer) must be disinfected with 1:100 bleach or EPA registered disinfectant before being removed from the dialysis station.”