Columbia Northeast Kidney Center

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 28883 Based on observation and interview, the dialysis clinic failed to ensure Patient Care Technician (PCT) #8, one of two PCTs observed assisting patients to the scale and out of the clinic after dialysis treatment, encouraged or asked a patient to perform hand hygiene after glove removal to prevent potential cross contamination in the clinic. The findings included: Observation on 6/10/24 at 10:02 AM revealed a patient at station 10 machine 6. Patient Care Technician (PCT) #3 discontinued the patient’s dialysis treatment, removing the needles with the patient holding pressure to the needle sites with a gloved hand. After the bleeding had stopped, PCT #3 reinforced tape over the needle sites, with the patient standing to get a blood pressure. At 10:30 AM, the patient removed the glove, did not perform hand hygiene, and went to the scale to get a weight with PCT #8. The patient touched the scale button, chalk board, and wall; and pressed the exit door button and left without performing hand hygiene. During an interview on 6/10/24 at 10:32 AM, PCT #8 was informed of the concern related to the patient not performing hand hygiene after glove removal and touching equipment and surfaces. PCT #8 verified the above observation.”

“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: 28883 Based on observations, interviews, and review of the policy “Hand Hygiene”, one of two Registered Nurses and one of four Patient Care Technicians observed failed to change gloves and/or perform hand hygiene at opportune times when indicated. The findings included: Observation on 6/10/24 at 11:38 AM revealed Patient Care Technician (PCT) #5 at machine 17, getting ready to start a dialysis treatment for a patient. After cleaning the patient’s skin to prepare it for inserting the needles; PCT #5 went to the clean supply cart (without removing gloves and performing hand hygiene first), and removed a tourniquet and placed it at the patient’s chairside. After cleaning the needle sites with alcohol pads, PCT #5 placed the tourniquet on the patient’s arm, removed his/her gloves and donned gloves; but did not perform hand hygiene before sticking 2 dialysis needles into the patient’s fistula. During this observation, Registered Nurse (RN) #2 came to assess the patient and removed an old bandaid that had drainage on it from the patient’s arm. The nurse did not change gloves or perform hand hygiene after removing/disposing of the bandaid and before administering intravenous Heparin to the patient at 11:47 AM. During an interview on 6/10/24 at 11:48 AM, RN #2 verified the observation. During an interview on 6/10/24 at 12:00 noon, PCT #5 verified the above observation. Review of the policy provided by the dialysis clinic staff entitled “Hand Hygiene” on 6/12/24 at 3:46 PM, revealed information for staff to perform hand hygiene after having direct contact with a patient’s intact intact skin, after contact with inanimate objects or environmental surfaces, and immediately after gloves are removed. The policy included information to change gloves when moving from a “dirty” area or task to a “clean” area or task, or when moving from a contaminated body site to a clean body site on the same patient, and between procedures.”

“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: 41879 Based on observation and staff interview, the End Stage Renal Dialysis facility failed to ensure procedures were in place to prevent cross contamination of disinfected items. Findings are: On 06/12/24 between 9:30 AM and 10 AM observations are conducted in the treatment area. At 9:35 AM a dirty sink is noted at the end of a counter. On the left side of the “dirty” sink was a Tupperware container filled with 1:100 bleach disinfectant. Blue clamps, used for applying pressure to the dialysis site and holding lines for each patient, were soaking in the disinfectant solution. On the right side of the “dirty” sink was a blue drape with three blue clamps and one large white clamp. Also noted on the blue drape were two dialysis wands. During observations, dialysis drip buckets were emptied in the “dirty” sink. The surveyor also observed normal saline bags brought to the dirty sink and laid in the sink to drain. At 9:45 AM, the clamps and the wands on the blue drape appeared wet with possible splatter noted coming from the “dirty” sink. One of the dialysis wands was partially off the blue drape and over the “dirty” sink area. At 9:47 AM, Patient Care Technician (PCT) #7 was observed coming to the dirty sink area and obtaining a large white clamp on the blue drape. PCT #1 also approached the blue drape and obtained two blue clamps and placed these at a clean dialysis station, with a new patient being seated at this station. In an interview with PCT #1 and Registered Nurse (RN) #3 on 6/12/2024 at 10:05 AM, the staff explained the blue drape on the right side of the sink is supposed to be the drying area for clean disinfected items. Staff verified the disinfected items appeared wet and it was possible items can get splashed from various liquids being emptied in the sink.”