Fmc - Freedom Dialysis Center

“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: 41879 Based on observations, interviews, and review of the policy “Hand Hygiene”, Two of three Patient Care Technicians (PCTs) observed, PCT #1 and #2, failed to use standard infection control practices for hand hygiene after glove removal. Findings included: On 04/08/2024 at 11:17 AM observation in the treatment area revealed #PCT 1 discontinuing a left arm fistula for a patient at Station 9. PCT #1 obtained gloves from a box on the wall and placed two gloves on top of the dialysis machine at Station 9. PCT #1 performs hand hygiene and donned the gloves from the top of the dialysis machine. PCT #1 assisted the patient to don a glove to their right hand. PCT #1 touched the dialysis machine and saline bag with gloved hands. PCT #1 was then observed taking out the first fistula needle. At no time did PCT #1 remove the contaminated gloves and perform hand hygiene before fistula needle removal. The findings were verified with PCT #1 on 04/08/2024 at 12:30 PM during an interview in the conference room. On 04/10/2024 at 10:15 AM, PCT #2 was observed providing care to a patient at Station #13. PCT #2, with gloved hands opened a temperature dot pack. The patient at Station #13 has a mask on. PCT #2 pulled the patient’s mask down and placed a temperature dot strip under the tongue of the patient. PCT #2 touched the machine. PCT #2 then returned to the patient and pulled the patient’s mask down to retrieve the temperature dot stick. PCT #2 pulled the patient’s mask back up. PCT #2 is then observed discontinuing the first fistula needle on the patient’s right arm. PCT #2 is observed holding pressure for approximately 4 to 5 minutes. PCT #2 asked a nurse to get extra gauze. Registered Nurse (RN) #1 dropped a package of 2 X 2 gauze on the bedside table drape, and asked PCT #2 if the gauze needed to be opened first. PCT #2 answered, “No.” PCT #2 continued to hold pressure to the access site for another 1 to 2 minutes. PCT #2 opened the package of 2 X 2 gauze and used the gauze to cover the first fistula site. At no time did PCT #2 remove his/her gloves after touching the patient’s mask twice and touching the dialysis machine. The findings were verified with PCT #2 during an interview on 04/10/2024 at 10:25 AM. Review of the policy provided by the dialysis clinic entitled “Hand Hygiene”, reads, “Decontamination using alcohol-based hand rub or by washing hands with antimicrobial soap and water should be done; before and after direct contact with patients, entering and leaving the treatment areas, 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.””

“MICROB MONITOR-SAMPLE BEFORE DISINFECT CFR(s): 494.40(a) 7.2 Microbial monitoring methods 7.2.1 General: samples before disinfect Samples should always be collected before sanitization/disinfection of the water treatment system and dialysis machines. This Standard is not met as evidenced by: 41879 Based on record review, interview, and review of the policy “Microbiological Monitoring of Dialysate”, the End Stage Renal Dialysis (ESRD) facility failed to obtain cultures before chemical disinfection for 10 of 29 hemodialysis machines reviewed. (Machines 1-10) Findings included: On 04/08/2024 at 2:30 PM, the dialysate cultures for 29 hemodialysis machines are reviewed. This ESRD facility bleaches the dialysis machines weekly every Tuesday. In January 2024 and February 2024, the 29 dialysis machines are bleached every Tuesday per the clinic records. Machines 1-5 were bleached on Tuesday 1/09/2024. The cultures for January were done on Machines 1-5 on 1/11/2024, two days after the chemical disinfection. In February 2024, Machines 5-10 were bleached on Tuesday 2/13/2024. The cultures for Machines 5-10 were collected on 2/15/2024, two days after chemical disinfection. The findings were verified with the Biomedical Technician during an interview on 04/11/2024 at 10:00AM. Review of the policy provided by the dialysis clinic entitled “Microbiological Monitoring of Dialysate,” reads, “ Sample Collection, Samples will be taken under the following conditions: No patient dialyzing on the machine, while the dialysis machine is running in stable conductivity and prior to daily cleaning and disinfection, this has been determined as worst case.””