Fkc Liberty Dialysis Doylestown

“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: 37972 Based upon staff observations (OBS) in the treatment area, facility policy and procedure review, and an interview with the facility staff, it was determined the facility failed to ensure hand hygiene and donning of new gloves during during discontinuation of dialysis and post dialysis access care for a central venous catheter for one (1) of two (2) observations (OBS #1), during access of an AV fistula for initiation of dialysis for one (1) of three (3) observations (OBS #1), and during discontinuation of dialysis and post dialysis access care for an AV fistula for one (1) of three (3) observations (OBS #3). Findings include: Review of facility policy titled ‘Hand Hygiene’ on January 30, 2026, at approximately 2:00 P.M. states, Policy: “Hands will be decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water: Before and after direct contact with patients... Before performing any invasive procedure such as vascular access cannulation or administration of parenteral medications, immediately after removing gloves, after contact with body fluids or excretion, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled, after contact with inanimate objects near the patient, when moving from a contaminated body site to a clean body site of the same patient, after contact with the dialysis wall box, concentrate, drain or water lines, and after contact with other objects within the patient station or treatment space.” Observations in the treatment area were conducted on January 28, 2026, from approximately 10:30 A.M. to 1:00 P.M., January 29, 2026, from approximately 9:30 A.M. to 12:00 P.M., and January 30, 2026, from approximately 9:30 A.M. to 11:30 A.M. revealed the following: OBS #1 during discontinuation of dialysis and post dialysis access care for a central venous catheter (CVC) on 1/29/2026 at 2:25 P.M. at Station #10, PCT (patient care technician) #2 performed hand hygiene, donned gloves, disinfected the CVC hubs and disconnected the blood lines. PCT #2 dropped the package containing the sterile port caps, reached between the patient ’ s leg and the side of the dialysis chair to retrieve the package, opened the package and applied the sterile port caps, without changing gloves and performing hand hygiene, or obtaining a new package of port caps. OBS #1 during access of AV fistula for initiation of dialysis on 1/28/2026 at 11:30 A.M. at Station #4, PCT #1 was observed performing hand hygiene and donning gloves, touching the machine keyboard, then removing the thermometer from the patient ’ s mouth. PCT #1 removed gloves, performed hand hygiene and donned new gloves. At 11:42 A.M. PCT #1 touched the dialysis machine, then connected the dialysis tubing to the patient catheters, touched the dialysis machine, tubing connections, blood pressure cuff, and the dialysis machine without changing gloves and performing hand hygiene per facility policy. OBS #3 during discontinuation of dialysis and post dialysis access care for an AV fistula on 1/29/2026 at 9:20 A.M. at Station #7, PCT #1 was observed performing hand hygiene and donning gloves. PCT #1 touched the dialysis machine, set up supplies for the procedure, touched the dialysis machine, clamped the dialysis tubing, disconnected the dialysis tubing, and touched the dialysis machine, then changed gloves and performed hand hygiene and donned new gloves. An interview with the facility Clinical Manager on January 30, 2026, at approximately 3:30 P.M. confirmed the above findings.”