Fkc New Bloomfield

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 39671 Based on a review of facility policy/procedure, treatment area observations, and an interview with the facility Clinical Manager, the facility failed to ensure staff followed standard infection control precautions by emptying the prime waste receptacle prior to disinfecting the dialysis station for one (1) of two (2) observations of ‘Cleaning and Disinfection of the Dialysis Station’ (Observation #2). Findings: A review was conducted of facility policy titled, ‘Prime Bucket Disinfection’ on March 20,, 2024 at approximately 1:00 p.m. ‘Prime Bucket Disinfection’ policy, reads, “Procedure: Step #1: Dispose of saline solution down any marked dirty sink or utility room hopper; Step #2: Clean all surfaces of the priming bucket; Step #3: Return clean priming bucket or approved receptacle to the machine” The CDC ‘Checklist: Dialysis Station Routine Disinfection’ ‘Part A: Before beginning routine disinfection of the dialysis station’ includes but is not limited to “Ensure that the priming bucket has been emptied”, ..........., “remove gloves and perform hand hygiene”. Part B: Routine disinfection of the dialysis station-After the patient has left station’ includes but is not limited to “Wear clean gloves”. “Apply disinfectant to all surfaces in the dialysis station .....”. *Note: Facility Procedure does not include “Emptying prime waste receptacle if present on the machine”/“Remove gloves, hand hygiene, don clean gloves” before “using disinfectant soaked cloth/wipe to visibly wet all machine ........” as listed in sequence on the ‘Centers for Medicare & Medicaid Services ESRD Core Survey Version 1.6” surveyor observation form. Observations conducted in the patient treatment area on March 19, 2024 between approximately 10:20 a.m. and 11:41 a.m. and on March 20, 2024 between approximately 9:55 a.m. and 10:06 a.m. revealed the following: Cleaning and Disinfection of the Dialysis Station Observation #2 :On 3/19/2024 at approximately 11:36 a.m. while observing ‘Cleaning and Disinfection of the Dialysis Station’ observation #2 of 2, employee #11 failed to empty prime waste receptacle after removing all bloodlines and disposable equipment and prior to disinfecting the dialysis station. An interview with the facility Clinical Manager on March 20, 2024 at approximately 2:00 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: 39671 Based on a review of facility policy/procedure, treatment area observations, and an interview with the facility Clinical Manager, the facility failed to ensure that clinical staff maintain aseptic technique for the care of vascular accesses, including intravascular catheters, for one (1) of two (2) ‘Central Venous Catheter (CVC) Exit Site Care’ observations (Observations #2) and for one (1) of two (2) ‘Discontinuation of Dialysis with Central Venous Catheter’ observations. (Observation #2 ) Findings: A review was conducted of facility policy titled, ‘Changing the Catheter Dressing Procedure’ on March 20, 2024 at approximately 1:30 p.m. ‘Changing the Catheter Dressing Procedure’, section, ‘Removal of Dressing and Inspection of Site’ reads, “Follow the steps below to remove a catheter dressing and inspect the exit site before initial of dialysis treatment: Step 1: Place an underpad under catheter limbs to protect work area and clothing; Step 2: Apply mask to patient and caregiver to help prevent contamination by airborne nasal...” A review was conducted of facility policy titled, ‘Termination of treatment Using a Central Venous Catheter and Optiflux Single Use Ebeam Dialyzer’ on March 20, 2024 at approximately 1:30 p.m. ‘Termination of treatment Using a Central Venous Catheter and Optiflux Single Use Ebeam Dialyzer’ section, ‘Prior to Termination Preparation’ reads, Follow the steps below to prepare for the termination of dialysis::... Step 3: Don gown and full-face shield with mask (or protective eyewear with full side shield and mask)... “ Observations conducted in the patient treatment area on March 19, 2024 between approximately 10:20 a.m. and 11:41 a.m. and on March 20, 2024 between approximately 9:55 a.m. and 10:06 a.m. revealed the following: Central Venous Catheter (CVC) Exit Site Care Observation #2 :On 3/19/2024 at approximately 11:05 a.m. while observing ‘Central Venous Catheter (CVC) Exit Site Care’ observation #2 of 2, for patient #6, station #8 employee #4; employee #4 failed to ensure face mask on patient # 8 was above nose throughout the procedure. Discontinuation of Dialysis with Central Venous Catheter Observation #2 :On 3/20/2024 at approximately 10:00 a.m. while observing ‘Discontinuation of Dialysis with Central Venous Catheter’ observation #2 of 2, for patient #8, station #2 employee #4; employee #4 failed to ensure face mask on patient # 8 was above nose throughout the procedure. An interview with the facility Clinical Manager on March 20, 2024 at approximately 2:00 p.m. confirmed the above findings.”