Fkc New Castle

“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: 31759 Based on review of facility policy, observation, and staff (EMP) interview, the facility failed to ensure the patient performed hand hygiene after glove removal for one (1) of two (2) observations of discontinuation of dialysis with an arteriovenous venous fistula (AVF1). Findings included: Review of facility policy on July 2, 2025, at 12 p.m., “Hand Hygiene ... Policy ... Hands Will Be ... Decontaminated using alcohol based hand rub ... Immediately after removing gloves.” During observation of discontinuation of dialysis with an AVF on June 30, 2025, at 12:35 p.m., the patient held his/her AVF needle site bandages with a gloved left hand to stop bleeding. Once bleeding had stopped, the patient removed his/her glove and left the station without performing hand hygiene. Interview with EMP6 on June 30, 2025, at 12:40 p.m. confirmed 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: 31759 Based on review of facility policy, observation, and staff (EMP) interview, the facility failed to ensure one (1) of two (2) staff (EMP7) wore appropriate personal protective equipment during discontinuation of dialysis with an arteriovenous fistula (AVF). Findings included: Review of facility policy on July 2, 2025, at 12 p.m., “Initiation and Termination of Treatment Using and Arteriovenous Graft or Fistula ... Infection Control ... Staff, patients, and care partners must use personal protective equipment (PPE), per policy: Personal Protective Equipment,” “Personal Protective Equipment ... Policy ... Personal protective equipment including a full-face or mask and protective eyewear with full side shield, ... must be worn to protect employees from blood or other potentially infectious materials (OPIM) ... PPE is used to protect employees from blood or OPIM when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis ...,” “OSHA Bloodborne Pathogen Standards ... Personal Protective Equipment - ... will be considered ‘appropriate’ only if it does not permit blood or other potentially infectious materials to pass through to or reach the employee’s ... mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used.” During observation of discontinuation of dialysis with an AVF at station 5 on June 30, 2025, at 2:15 p.m., EMP7 removed needles from patient’s AVF and applied dressings to stop bleeding. EMP7 wore a mask and safety glasses but his/her mask did not cover his/her nose. Interview with EMP7 after the observation at 2:20 p.m. confirmed findings.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 31759 Based on review of facility policy, observation and staff (EMP) interview, the facility failed to ensure one (1) of two (2) staff (EMP7) maintained aseptic technique for the care of intravascular catheters. Findings: Review of facility policy on July 2, 2025, at 12 p.m., “Changing the Catheter Dressing Procedure ... Removal of Dressing and Inspection of Site ... 5 Inspect and remove the old dressing. ... 8 Discard dressing and remove gloves. Perform hand hygiene. Prepare Dressing Supplies ... Using aseptic technique, apply the catheter dressing over dry exit site.” During observation of central venous catheter care at station 10 on July 1, 2025, at 10:45 a.m., EMP7 removed patient’s old dressing, and without performing a glove change and hand hygiene, cleansed patient’s exit site and applied a new dressing. Interview with EMP16 (clinic manager), who was present at the time of observation, confirmed findings.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 31759 Based on review of facility policy, logs, and staff (EMP) interview, the facility failed to ensure the results of chlorine monitoring were recorded on a log sheet every 4 hours for one (1) of four (4) daily chlorine tests while patients were dialyzing. Findings included: Review of facility policy on July 2, 2025, at 12 p.m., “Carbon Filtration Monitoring for Incenter Water Systems Policy ... All tests must be completed within 4 hours ... Document total chlorine test results on the appropriate TCL-1 log in CMMS. ... Documentation ... Routine Total Chlorine Testing will be documented in CMMS or paper log printed from CMMS as stated in the ‘Policy’ section of this document.” Review of chlorine result logs on July 2, 2025, at 9 a.m. did not show results were recorded every 4-hours on 6/6/2025 while patients were dialyzing. More specifically, three (3) chlorine test results from 6/6/2025 were logged at 4:34 a.m., 7:26 a.m., and 10:26 a.m. with no other testing completed, however two patients were dialyzing past the 4-hour testing time frame (due at 2:26 p.m.): CR1 discontinued dialysis at 2:35 p.m., and CR2 discontinued dialysis at 4:44 p.m. Interview with EMP1 on July 2, 2025, at 1:30 p.m. confirmed above findings and noted the omission on 6/6/2025 was a documentation error.”