Usrc Travelers Rest Dialysis

“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 facility policy “Hand Hygiene”, two of three Patient Care Technicians (PCTs) observed, PCTs #2 and #3, failed to perform hand hygiene to prevent potential cross contamination. The findings include: Observation on 7/1/24 at 9:02 AM of the treatment room floor revealed Patient Care Technician (PCT) #3 at station #5, machine #9, caring for a patient whose treatment had finished. PCT #3 donned gloves, took the patient’s temperature with a thermometer, documented the result on the hemodialysis machine screen then went to a clean supply cart and retrieved an alcohol pad and used it to clean the thermometer. PCT #3 did not remove gloves and perform hand hygiene after touching the hemodialysis machine and/or prior to going to the clean supply cart. During an interview on 7/1/24 at 9:25 AM, PCT #3 stated s/he usually tries to perform hand hygiene before leaving the station. Observation on 7/1/24 at 10:10 AM of the treatment room floor revealed PCT #2 at station #7, machine #11. PCT #2 with gloved hands removed a Band-Aid from the patient’s arm, folded the Band-Aid, and placed it in the trash. PCT #2 then opened a needle pack and removed 2 dialysis needles. PCT #2 then felt the patient’s access (fistula), listened to the access with a stethoscope (cleaning the stethoscope before and after with an alcohol pad), then picked up the needles with the same gloves, set them down, and placed a tourniquet on the patient’s arm. PCT #2 had not removed the gloves and/or performed hand hygiene after removing the Band-Aid. During an interview on 7/1/24 at 10:32 AM, PCT #2 verified the observation. Review on 7/2/24 at 2:44 PM of the facility policy, entitled “Hand Hygiene”, revised 08/2020, revealed hand hygiene will be performed before and after touching a patient, before clean/aseptic procedure, after body fluid exposure risk, and after touching patient surroundings to include the dialysis machine.”

“IC-TRANSDUCER PROTECTORS-NOT WETTED/CHANGED CFR(s): 494.30(a)(1)(i) Use external venous and arterial pressure transducer filters/protectors for each patient treatment to prevent blood contamination of the dialysis machines’ pressure monitors. If the external transducer protector becomes wet, replace immediately and inspect the protector. If fluid is visible on the side of the transducer protector that faces the machine, have qualified personnel open the machine after the treatment is completed and check for contamination. This includes inspection for possible blood contamination of the internal pressure tubing set and pressure sensing port. If contamination has occurred, the machine must be taken out of service and disinfected using either 1:100 dilution of bleach (300-600 mg/L free chlorine) or a commercially available, EPA-registered tuberculocidal germicide before reuse. Change filters/protectors between each patient treatment, and do not reuse them. Internal transducer filters do not need to be changed routinely between patients. This Standard is not met as evidenced by: 28883 Based on interview and review of facility policy, the dialysis facility failed to ensure one of two nursing staff, Registered Nurse (RN) #2, interviewed about infection control measures for a wetted transducer protector was not knowledgeable about the action to take if blood was noted on the transducer protector side facing the machine. The findings include: During an interview on 7/3/24 at 9:00 AM, RN #2 was asked what action to take if the transducer protector was observed to have blood on the front side. RN #2 stated s/he would change the transducer protector, inspect the side facing the machine and if there was blood/red visible on the backside, s/he would pull the machine and disinfect it with bleach. When asked to elaborate, the nurse stated s/he would pull the machine immediately and have the Patient Care Technicians bleach disinfect the machine before it could be used again. When informed this was not the correct answer, RN #2 asked if s/he could find out the correct answer. RN #2 returned and reported that the Biomedical Technician would be notified and the machine taken out of service after the dialysis treatment was completed. Review on 7/3/24 at 9:26 AM of the facility policy, entitled “Intradialytic Monitoring of Patient”, revised 09/2020, revealed information that “If transducer filter becomes wet, replace immediately. Inspect the side of the protector that faces the machine. “...If fluid is visible, biomed tech will be notified and machine taken out of service after dialysis treatment is completed...”.”

“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: 22313 Based on observation, interview and review of facility policy, the dialysis facility failed to ensure one of three PCTs observed, Patient Care Technician (PCT) #2, did not disinfect the prime waste bucket after patient use. Findings include: Observation on 07/01/24 at 11:05 AM showed Patient Care Technician PCT#2 dumped the saline from the prime waste container after patient treatment. PCT#2 returned the prime waste container to the hemodialysis machine without sanitizing it inside or out. During an interview on 07/01/24 at 11:15 AM, PCT#2 stated, “I usually just return it to the machine then go over the whole machine before putting on the next patient”. After the interview, PCT#2 was observed setting up the machine for the next patient without disinfection of the prime waste bucket. Review of the facility’s policy titled, “Disinfection and Cleaning of Dialysis Machine Equipment,” showed that staff are to disinfect all surfaces of the prime waste bucket, inside and out, with a cloth moistened in a solution of 1 part bleach to 100 parts water before returning it the to the dialysis machine.”

“CARBON ADSORP-ACTION IF FIRST TEST + CFR(s): 494.40(a) 5.2.5 Carbon adsorption: action if first test positive When samples from the first sampling port are positive for chlorine or chloramine, operation may be continued for a short time (up to 72 hours) until a replacement bed is installed, provided that samples from the second sampling port remain negative. The replacement bed should be placed in the second position, and the existing second bed should be moved to the first position to replace the exhausted bed. If it is not possible to rotate the position of the beds, both beds should be replaced. This Standard is not met as evidenced by: 22313 Based on observation, interview and review of facility policy, the dialysis facility failed to ensure one of two staff observed performing the Total Chlorine test, Patient Care Technician (PCT) #1, was unable to verbalize the appropriate port to check for chlorine breakthrough. Findings include: During observation on 07/01/24 at 10:50 AM, Patient Care Technician (PCT)#1 and Registered Nurse (RN)#1 performed the Total Chlorine test correctly. PCT#1 performed the test on the water on the first carbon port. PCT#1 was then asked, “What would you do if the test failed?” PCT#1 stated the next step was to go to the second carbon port and repeat the test. PCT#1 began looking for the second port between the two carbon tanks. PCT#1 then came back to the bank of ports. PCT#1 then pointed to the water softener port and indicated that is where she would go for the test. RN#2 was asked if that was the right port to check and she said “No”, that s/he would check the carbon polisher port. The test procedure is posted in the water room and the water ports are labeled. During an interview on 07/01/24 at 11:12 AM, PCT#1 stated, “I got confused. I’m sorry.””

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 22313 Based on record review, interview and review of facility policy, the dialysis facility failed to ensure the weekly documentation for weekly machine bleach disinfection was completed for 3 of 15 hemodialysis machines reviewed. (Dialysis machines #1, #10 and #12). Findings include: Record review on 07/03/24 at 12:30 PM of the documentation for bleach disinfection of the hemodialysis machines showed missed dates of disinfection. Documentation for Machine #1 showed no bleach disinfection for 05/07/24, 05/14/24, 06/11/24 and 06/18/24. Machine #10 showed no documentation of bleach disinfection for 05/14/24, 05/21/24, 06/4/24, 06/11/24 and 06/18/24. Machine #12 showed no documentation of bleach disinfection for 05/14/24 and 06/18/24. During an interview on 07/03/24 at 1:30 PM, the Biomedical Technician (BMT) stated, “I talked to staff. They said they did it, just did not document it correctly. I am going to take care of that. All fifteen of the machines were missing documentation for the bleach documentation.” Review of the facility’s policy titled, “Disinfection Protocols,” dated 04/2022, showed that once weekly, the dialysis machine(s) must go through an acid rinse followed by bleach disinfection. Dialysis machine disinfection must be documented on the Machine Disinfection Log.”