Fkc Carbon County

“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: 36372 Based on a review of facility policy/procedure, observations, and an interview with the facility Administrator, the facility failed to ensure staff followed infection control protocols, included but not limited to, hand hygiene/don clean gloves, for two (2) of two (2) ‘Parenteral Medication Preparation and Administration’ observations (Observation #1, Observation #2). Findings include: A review was conducted of facility policy/procedure on September 11, 2024, at approximately 11:30 a.m. ‘Medication Preparation and Administration Procedure’ (Setting: IC, HT) ‘Medication Administration Procedure’ Step (1) “Wash hands. Apply PPE. ....(3) Take the medication to the patients chair or bedside.” Observations conducted in the patient treatment area on September 9, 2024 between approximately 9:15 a.m. and 1:10 p.m. revealed the following: Observation #1 of 2: During observation of ‘Parenteral Medication Preparation and Administration’ on 09/09/24 at approximately 12:55 p.m., of patient #2, Employee #7 at station #3 did not perform hand hygiene after preparing the patient medication and prior to administering the medication. Employee #7 only donned clean gloves. Observation #2 of 2: During observation of ‘Parenteral Medication Preparation and Administration’ on 09/09/24 at approximately 1:10 p.m., of patient #1, Employee #2 at station #2 did not perform hand hygiene after preparing the patient medication and prior to administering the medication. Employee #2 only donned clean gloves. An interview with the facility Administrator on September 11, 2024 at approximately 12:00 p.m. confirmed the above 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: 36372 Based on a review of facility policy/procedure, observations, and an interview with the facility Administrator, the facility failed to ensure that clinical staff maintain aseptic technique for the care of vascular accesses, including intravascular catheters for two (2) of two (2) ‘Central Venous Catheter (CVC) Exit Site Care’ and ‘Initiation of Dialysis with Central Venous Catheter’ observations (Observation #1, Observation #2). Findings: A review was conducted of facility policy/procedure on September 11, 2024, at approximately 11:30 a.m. Policy ‘Changing the Catheter Dressing Procedure’ (Setting: IC, HT) ‘Applying the Dressing’ (1) Using aseptic technique, apply the catheter dressing ... Policy ‘Initiation of Treatment using a Central Venous Catheter (CVC) and Optiflux Single Use Ebeam Dialyzer’ (Setting: IC, IPS) ‘Prior to Initiation: Assessment and Machine Parameters’ step (9) states “.... doff (remove) gloves, perform hand hygiene then don new gloves.” ‘Preparing the Catheter: Disinfection of the Catheter Connections, Heparin Removal, Flushing the Catheter and Heaprin Administration’ step (1) states “Check to make sure catheter clamps are closed. Step (2) states “Remove cap from clamped arterial limb.” Step (3) states “Using a sterile alcohol pad .....” Observations conducted in the patient treatment area on September 9, 2024 between approximately 9:15 a.m. and 1:10 p.m. revealed the following: Observation #1: On 09/11/24 at approximately 10:35 a.m. while observing ‘Central Venous Catheter Exit Site Care’ observation #1, for patient #6, station #1, employee #4 did not remove gloves/perform hand hygiene/don clean gloves after applying the sterile dressing and before initiating dialysis. Employee #4 removed gloves/performed hand hygiene after cleansing the area around the CVC exit site and prior to applying the sterile dressing. Observation #2: On 09/11/24 at approximately 12:40 p.m. while observing ‘Central Venous Catheter Exit Site Care’ observation #2, for patient #7, station #4, employee #4 did not remove gloves/perform hand hygiene/don clean gloves after applying the sterile dressing and before initiating dialysis. Employee #4 removed gloves/performed hand hygiene after cleansing the area around the CVC exit site and prior to applying the sterile dressing. An interview with the facility Administrator on September 11, 2024 at approximately 12:00 p.m. confirmed the above findings.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 36372 Based on a review of facility policy/procedure, observations, and an interview with the facility Administrator, the facility failed to ensure clinical staffs personal belongings/food was stored out of/away from the patient treatment area, per policy/procedure for general cleanliness and infection control guidelines, for one (1) of one (1) treatment floor observations (Observation #1). Findings: A review was conducted of facility policy/procedure on September 11, 2024, at approximately 11:30 a.m. Policy ‘General Cleanliness and Infection Control Guidelines’ (Setting: IC, HT) ‘Purpose’ “The purpose of this policy is to provide guidance for FKC staff on preventing the spread of infectious disease and maintain a clean, safe, and aesthetically pleasing environment for patients, staff, and visitors.” ‘Policy’ “All areas must be kept clean and organized ...... ....Eating, drinking, .... are prohibited in work areas where there is reasonable likelihood of occupational exposure.” Observations conducted in the patient treatment area on September 9, 2024 between approximately 9:15 a.m. and 1:10 p.m. revealed the following: Observation #1: On 09/09/24 at approximately 9:20 a.m. while conducting treatment area observations near the staff work station next to the ‘Lab Prep’ room, a black backpack was observed hanging on a chair at the station. The backpack had unwrapped/unopened syringes (containing saline) in the side pocket. A pair of white shoes were under the work station counter. An open small black carry purse/bag contents included but not limited to a clear bag of grapes. An open small red purse/bag contained pens, pencils, post-its, a Tylenol bottle, and a wrapped piece of candy. The charge nurse (employee #7) was notified at approximately 9:25 a.m. and it was determined the above items belonged to employee #3, who was present and working at the time. An interview with the facility Administrator on September 11, 2024 at approximately 12:00 p.m. confirmed the above findings.”