Davita Selmer 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: 33763 Based on policy review, observation and interview, the facility failed to ensure hand hygiene was performed according to facility policy to prevent the spread of infectious bacteria by 2 of 8 (CCHT #1 and LPN #1) staff observed on the treatment floor. The findings included: 1. Review of the facility policy titled, “Infection Control for Dialysis Facilities” revised April 2023 revealed, “...All teammates...will perform hand hygiene...prior to gloving and immediately after removal of gloves...after patient and dialysis delivery system contact...between patients even if the contact is casual...before touching clean areas such as supplies, supply cart and chairside keyboard/mouse...Gloves should be changed when...going from a “dirty” area or task to a “clean” area or task...When moving from a contaminated body site to a clean body site of the same patient...After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient’s dialysis delivery system...” 2. Observations on the treatment floor at Station #11 on 4/7/2025 at 10:10 AM, revealed CCHT #1 preparing to discontinue Random Patient #6’s hemodialysis treatment via an AVF. CCHT #1 performed hand hygiene, donned gloves, and began reinfusing the extracorporeal circuit, removed her gloves, performed hand hygiene and donned new gloves. The CCHT assisted the Patient to the standing position, assessed the Patient’s blood pressure, and assisted the Patient sit back down. CCHT #1 removed her gloves, donned new gloves without performing hand hygiene, and removed the venous needle from the Patient’s arm. CCHT #1 failed to perform hand hygiene after removing her gloves and prior to donning new gloves. 3. Observations on the treatment floor at Station #8 on 4/7/2025 at 1:20 PM, revealed LPN #1 donned gloves without performing hand hygiene and took supplies to discontinue hemodialysis treatment for Random Patient #1 via a CVC. The LPN placed the supplies on the chairside table, removed her gloves, then walked to Station #10 where Random Patient #2’s hemodialysis treatment had just ended via an AVF. Without performing hand hygiene, LPN #1 donned new gloves and stopped the dialysis treatment. The alarm began sounding at Station #11 where Random Patient #3 was undergoing hemodialysis treatment. LPN #1 removed her gloves, donned new gloves without performing hand hygiene and silenced the alarm at Station #11 then removed her gloves. LPN #1 donned new gloves without performing hand hygiene, returned to Station #10 and began reinfusing the extracorporeal circuit on Random Patient #2. The alarm at Station #11 sounded again. LPN #1 removed her gloves, donned new gloves without performing hand hygiene, and silenced the alarm at Station #11. LPN #1 removed her gloves then walked to Station #8 where Random Patient #1’s hemodialysis treatment via a CVC had ended. Without performing hand hygiene, LPN #1 donned new gloves, and began reinfusing the extracorporeal circuit on Random Patient #1 via a CVC. Once the reinfusion was completed, LPN #1 disconnected the tubing, cleaned the catheter hubs with alcohol and applied new end caps and a dressing. LPN #1 removed her gloves and began packing Random Patient #1’s belongings into his bag. Without performing hand hygiene, LPN #1 donned new gloves, assessed the Patient’s BP and removed the BP cuff from Random Patient #1’s arm and assisted the Patient off the treatment floor. LPN #1 entered data onto the computer next to Station #8 and removed her gloves. LPN #1 walked to Station #10, donned new gloves without performing hand hygiene, and disconnected Random Patient #2’s venous needle from his access site, applied a pressure bandage and clamp, then removed her gloves. Without performing hand hygiene, LPN #1 walked back to Station #8, donned new gloves, and removed Random Patient #1’s blood lines and dialyzer from the machine and discarded them. LPN #1 cleaned the thermometer with a bleach wipe and placed it on the computer cart between Station #8 and Station #9, then emptied and cleaned the prime waste container from Station #8 and placed it back onto the machine. LPN #1 then picked up another thermometer from the nurse’s station, cleaned it and placed it between Station #12 and #13 and removed her gloves. Without performing hand hygiene, LPN #1 returned to Station #10, donned new gloves, and removed the clamp from Random Patient #2’s access site, applied a new pressure dressing, then removed the arterial needle and applied a pressure dressing and clamp to the site. The alarm at Station #15 began sounding. LPN #1 removed her gloves, walked to Station #15 where Random Patient #4 was undergoing hemodialysis treatment. The LPN donned new gloves, silenced the alarm, and removed her gloves. LPN #1 donned new gloves and rolled a chair to Station #12 where Random Patient #5’s hemodialysis treatment via an AVF had just ended. LPN #1 began reinfusing the extracorporeal circuit, removed her gloves and folded the Patient’s blanket and put it in his bag. Without performing hand hygiene, LPN #1 donned new gloves and removed the venous needle from Random Patient #5’s arm and applied a pressure dressing and held pressure to the site. CCHT #2 replaced LPN #1 at Station #12. LPN #1 removed her gloves, returned to Station #10, donned new gloves, and removed the second clamp from Random Patient #2’s access site and applied a new pressure dressing. LPN #1 failed to perform hand hygiene before and/or after glove use, when moving from contaminated sites to clean sites, and when moving from patient to patient repeatedly. LPN #1 was not observed performing hand hygiene at any time during the continuous observations on the treatment floor. 4. During an interview on 4/8/2025 at 3:00 PM, the FA verified staff should perform hand hygiene after removing gloves, when moving from clean to dirty sites, before and after patient contact, and when moving from one patient to another patient.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 33763 Based on facility policy review, observation, and interview, the facility failed to ensure all open, multi-dose vials of medication were labeled and not expired in 1 of 2 (medication storage refrigerator) medication storage areas. The findings included: 1. Review of the facility’s “Medication Policy” revised October 2023 revealed, “...Medications containing a preservative must be discarded 28 days after opening or accessed...Each vial is labeled with the initials of the person opening the vial and the expiration date...” 2. Observations in the medication storage refrigerator on 4/7/2025 at 11:20 AM, revealed 1 opened and unlabeled multi-dose vial of Tuberculin Purified Protein Derivative (PPD). 3. During an interview on 4/7/2025 at 3:05 PM, RN #1 verified the opened multi-dose vial of PPD was unlabeled and should be discarded after 28 days. During an interview on 4/9/2025 at 10:24 AM, the FA verified all opened multi-dose vials of medication should be labeled with an open date and expiration date.”

“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: 33763 Based on facility policy review, observation, and interview, the facility failed to ensure policies and procedures to reduce the risks of CVC related infections were followed by 1 of 3 (LPN #1) staff members observed caring for patients with a CVC. The findings included: 1. Review of the facility policy titled, “Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure” revised October 2024 revealed, “...Upon Completion of Dialysis...Perform hand hygiene per procedure. Put on PPE ...Set up new clean field with all appropriate supplies on a new clean, moisture proof barrier...Discard used barrier that was used during treatment and place a new clean, moisture proof barrier under catheter to prevent contamination...Remove gloves and discard, perform hand hygiene per procedure and re-glove...Remove gloves and discard. Perform hand hygiene per procedure and re-glove...clean exit site...” 2. Observations on the treatment floor at Station #8 on 4/7/2025 at 1:20 PM, revealed LPN #1 preparing to discontinue Random Patient #1’s hemodialysis treatment via a CVC. LPN #1 failed to perform hand hygiene prior to beginning the procedure; failed to place a clean moisture proof barrier under the catheter limbs prior to the procedure; failed to remove her gloves, perform hand hygiene, and don new gloves after reinfusing the extracorporeal circuit; and failed to perform hand hygiene after removing her gloves when the procedure was completed. 3. During an interview on 4/8/2025 at 3:00 PM, the FA verified staff should perform hand hygiene prior to patient care and after removing gloves. During an interview on 4/9/2025 at 10:24 AM, the FA verified a clean, moisture proof barrier should be placed under the catheter limbs prior to discontinuing hemodialysis treatment via a CVC.”