Usrc Carlisle

“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: 39671 Based on observations, reviews of facility policy, and an interview with the interim facility Administrator (EMP# 1), it was determined the facility failed to ensure the staff followed infection control protocols, included but not limited to, hand hygiene/don clean gloves, for one (1) of two (2) ‘Central Venous Catheter Exit Site Care’ observations. ( ‘Central Venous Catheter Exit Site Care’ observation #1) Findings include: Policy, ‘Dialysis Catheter Dressing Change Procedure Policy # C-IC-0070’ was reviewed on April 29, 2025 at approximately 11:00 a.m. revealed, “PROCEDURE:... 5. Remove and discard old exit site dressing. Remove gloves, perform hand hygiene and don clean gloves....8. Using aseptic technique, cleanse the skin surrounding the exit site with the appropriate skin antiseptic...” Clinical dialysis treatment area observations were conducted on April 28, 2025 between 10:01 a.m. and 2:49 p.m. revealed the following: ‘Central Venous Catheter Exit Site Care’ observation #1: On April 29, 2025 at approximately 10:57 a.m. employee # 11 removed old dressing, began to cleanse area CVC exit site with antiseptic and then removed gloves, performed hand hygiene and donned clean gloves. Employee # 1 failed to remove gloves, perform hand hygiene and don clean gloves after removing old dressing and prior to cleansing area around the CVC exit site with antiseptic. An interview with EMP# 1 on April 29, 2025 at approximately 2:45 p.m. confirmed the policy as current and confirmed the findings above.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 39671 Based on observations, reviews of facility policy, and an interview with the interim facility Administrator (EMP# 1), it was determined the facility failed to ensure dialysis equipment including but not limited to dialysis chairs and rolling stools are maintained according to manufacturer’s directions for five (5) of twelve (12) dialysis chair observations. (Dialysis Chair Observation #1- Dialysis Chair Observation # 5) Findings include: Policy for dialysis chairs/equipment was requested but policy was not provided. Clinical dialysis treatment area observations were conducted on April 28, 2025 between 10:01 a.m. and 2:49 p.m. revealed the following: Dialysis Chair Observation # 1: On 4/28/25, Dialysis chair located at station # 1 had cracking/peeling/ripped fabric on the top of the seat cushion and on the leg rest. Dialysis Chair Observation # 2: On 4/28/25, Dialysis chair located at station # 6 had cracking/peeling/ripped fabric on top of the seat cushion and on the right armrest toward the middle of the armrest. Dialysis Chair Observation # 3: On 4/28/25, Dialysis chair located at station # 8 had cracking/peeling/ripped fabric on the top of the seat cushion. Dialysis Chair Observation # 4: On 4/28/25, Dialysis chair located at station # 9 had cracking/peeling/ripped fabric on the top of both armrests toward the front. Dialysis Chair Observation # 5: On 4/28/25, Dialysis chair located at station # 12 had cracking/peeling/ripped fabric on the top of the left armrest toward the front. An interview with EMP# 1 on April 29, 2025 at approximately 2:45 p.m. confirmed the policy as current and confirmed the findings above.”