Lebonheur Childrens Hosp 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: 33487 Based on policy review, observation and interview the facility failed to ensure proper hand hygiene was performed during initiation of a dialysis treatment for 1 of 2 (RP #1) patients observed with a CVC. The findings include: 1. Review of the facility’s “Hand Hygiene Policy,” dated 4/29/2022, revealed “ ...To define the process for cleaning hands in order to reduce the risks of transmitting microorganisms from one person to another or from one site to another on the same patient. It is [named hospital system that owns dialysis unit] intention to reduce transmission of pathogenic microorganisms to patients and Associates throughout the organization...Hand hygiene indications...Before and after physical contact with a patient and/or his or her immediate environment whether or not gloves are worn, and between different site/care activities on the same patient...Before and after handling patient care devices such as intravascular catheters, urinary closed drainage systems and respiratory equipment...before donning gloves and after removing gloves...Perform hand hygiene after even brief patient care activities that involve touching patients, regardless of the patient’s isolation status...” 2. Observations on 4/15/2024 beginning at 11:05 AM, revealed RN #1 sanitized her hands and donned gloves. She used her right pointer finger to push her glasses up and proceeded to program the dialysis machine. She placed the heparin syringe on the heparin pump. RN #1 failed to sanitize her hands and change gloves after she touched her glasses. RN #1 was then observed to sanitize her hands and don her right glove before dropping her left glove on the floor. She picked up to glove that was on the floor and disposed of the glove. She then retrieved and donned her left glove without sanitizing her hands. RN #1 pulled TPA from the CVC ports and flushed both ports with normal saline. She then hooked up the arterial line and touched the dialysis machine and then hooked up the venous line and touched the dialysis machine. RN #1 failed to sanitize her hands and change her gloves after touching the dialysis machine and before touching the CVC ports. She doffed both of her gloves, sanitized hands, redonned gloves, pushed her glasses back with her finger and programed the dialysis machine. 3. During an interview on 4/16/2024 at 3:05 PM, the Administrator/Senior Director of Nursing stated “...one should always sanitize hands between glove changes...the machines [dialysis] are considered dirty...the nurse should have sanitized her hands and donned new gloves after she picked the glove off the floor...” The Administrator shook his head “No” when informed the RN #1 touched her glasses with her gloved finger.”

“RO-CHEMICAL ANALYSIS-FREQUENCY CFR(s): 494.40(a) 6.2.7 Reverse osmosis: Chemical analysis: frequency Chemical analysis for the contaminants listed in 4.1.1 (Table 1) should be done when the RO system is installed, when membranes are replaced, and at not less than annual intervals thereafter to ensure that the limits specified in 4.1.1 are met (see Table 1). Chemical analyses should be done when seasonal variations in source water suggest worsening quality or when rejection rates fall below 90 %. This Standard is not met as evidenced by: 19001 Based on document review and interview, the dialysis facility’s administration failed to ensure the chemical AAMI analysis was completed annually. The findings included: 1. Review of the facility’s Environmental Water Testing to AAMI Standards revealed the last tests were collected on 2/17/2023 and resulted on 2/22/2023. 2. During an interview on 4/15/2024 at 2:45 PM, the surveyor asked the Administrator/Senior Director of Nursing for the facility policy regarding AAMI water testing. During an interview on 4/16/2024 at 11:35 AM, the Administrator/Senior Director of Nursing stated he was unable to find a specific policy regarding AAMI testing. The Administrator further stated he agreed that AAMI water testing should have been done in February 2024. The Administrator stated, “He [Biomedical technician] is drawing them today.””