Dci Holston River Clinic

“IC-CATHETERS:GENERAL CFR(s): 494.30(c)(2) (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection as the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html This Standard is not met as evidenced by: 51389 Based on facility policy review, observation and interviews, the facility failed to ensure the staff followed appropriate infection control measures when accessing a central venous catheter (CVC a surgically inserted dialysis access) and performing a CVC site dressing change for 1 patient (#3) out of 3 patients observed during initiation of dialysis using a CVC catheter. The findings include: Review of the policy titled, “Initiating Dialysis Using a Catheter with Catheter Dressing Change and Flow/Art Valve/Cap,” dated 8/2024, revealed “...Purpose to properly prepare site Pre and Post use and to provide for an adequate and safe hemodialysis using a subclavian catheter [a tube placed in the main vein in the chest/clavicle area for hemodialysis]...Place chux [disposable water absorbent pad] under patients CVC [Central Venous Catheter] ports to provide a clean filed. All equipment must be obtained and assembled prior to beginning procedure to ensure smooth and efficient technique with minimal time waste, maintenance of aseptic [purposeful prevention of microbe contamination] technique... remove patient clothing at catheter site to allow complete access to catheter site. Place a clean chux between patient’s clothes and catheter ports...maintaining aseptic technique, take the disinfectant swab stick...scrub catheter exit site and allow prep to dry...using aseptic technique, apply catheter dressing to cover catheter...open one antiseptic pad for each catheter port, wrap pad around end of...cap and scrub prior to...cap removal...if it is...cap change day remove the arterial valve and scrub the hub of arterial port for 30 seconds. Scrub the side [threads] and end of the hub thoroughly with friction, making sure to remove any residue...catheter hubs should always be handled aseptically. Once disinfected the catheter hubs should not be allowed to touch non-sterile surfaces. This might be best performed by holding them until the antiseptic dries...if not...cap change day scrub the old valve with first alcohol pad for 30 seconds, then the second alcohol pad for 30 seconds...if changing cap attach a new value to a dry 10 cc (cubic centimeter) sterile syringe taking care to keep technique sterile. If not changing the cap, then attach a 10-cc sterile syringe without a needle onto the existing arterial catheter clamp...connect the catheter ends to the bloodlines securely...” Medical record review revealed Pt #3 was admitted on 7/21/2025 with diagnoses including End Stage Renal Disease following a kidney transplant failure. During an observation on 12/15/2025 at 11:55 AM, in the patient care area, RN (registered nurse) A was observed removing an old CVC dressing from Pt #3’s exit site at her right chest. Pt #3’s jacket was pushed away from the CVC exit site, and RN A cleansed the site per policy. RN A turned his body around to pick up a new dressing and Pt #3’s jacket moved back over and covered the cleansed exit site. RN A turned around and pulled the jacket to the side again and immediately covered the now contaminated site with a new sterile dressing instead of recleaning the site. Continued observation revealed RN A removed the hubs off both ends of the CVC, one at a time, and performed scrubbing the hub with alcohol per policy. After this was completed, RN A was observed laying the open and uncapped ends of the CVC limbs down on the nonsterile barrier below the catheter , leaving the open CVC exposed to a nonsterile environment. Interview on 12/16/2025 at 2:30 PM, with the Facility Administrator (FA) revealed when changing the dressing of a CVC, the site must be cleaned from the exit site outward in a circular motion. The FA stated the site must remain free from clothing until the site has dried and a new dressing has been applied. The FA further verified if a patient’s clothing slips and covers the open exposed exit site, the site is considered contaminated and should be re-cleaned. The FA continued to validate when initiating dialysis utilizing a CVC, the non-capped ends of the CVC should never be laid down on the nonsterile barrier without a sterile syringe attached to the open end to create a barrier.”

“SOFTENERS: TESTING HARDNESS/LOG CFR(s): 494.40(a) 6.2.4 Softeners: Testing hardness/log Users should ensure that test accuracy and sensitivity are sufficient to satisfy the total hardness monitoring requirements of the reverse osmosis machine manufacturer. Total hardness of the water exiting the water softener should be measured at the end of each treatment day. Water hardness test results should be recorded in a water softener log. This Standard is not met as evidenced by: 51389 Based on review of facility policy, review of facility Water System Logs, observations and interviews, the facility failed to ensure the water hardness monitoring policy was being followed by testing the water hardness at the beginning and end of each dialysis treatment day for the last 90 days. The findings include: Review of the policy titled, “Daily Water Treatment Monitoring,” revealed “...Water used for all components of the Hemodialysis treatment must be treated so that safe effective care can be rendered. The Water Treatment System will be monitored on a daily basis to assure that the water quality meets or exceeds the AAMI Standards [Association for the Advancement of Medical Instrumentation]...Although these parameters are not directly indicative of treated water quality, monitoring them can help ensure that the system is operating within the manufacturer’s specifications and aid in maintain the performance of the RO and ensure reliability...Hardness testing...perform at the beginning and at the end of each dialysis treatment day. Monitor for ? GPG [grains per gallon] or 17.1 ppm [parts per million]...the purpose of the softener removing the hardness is to extend the life span of the RO [reverse osmosis] membranes...” During an observation on 12/15/2025 at 11:45 AM, in the Water Treatment Room revealed Water System Logs where the CHHT (Certified Hemodialysis Technician) placed the results from testing the water hardness. The times the water hardness checks were logged, was consistently at start up in the morning and then again between 11:00 AM - 1:00 PM, Monday through Saturday. At the bottom of the form, it said “Water Hardness to be checked at the beginning of the day and at the end of the day.” During an interview on 12/15/2025 at 11:50 AM, with CHHT #1 revealed when she did the Water System checks, she checked the water hardness in the morning and at the mid-day check between 11:00 AM - 1:00 PM. CHHT #1 verified the bottom of the Water System Log said to check at the beginning of the day and at the end of the day. She stated she did not notice that and she had been checking it at these times since she was taught. During an interview on 12/16/2025 at 1:30 PM, with the Equipment Technician confirmed the facility policy “Daily Water Treatment Monitoring” stated the water hardness was to be checked at the beginning of the day and at the end of the day. She stated “...I asked the staff why they did it at midday and was told they thought they were supposed to check it at that time of the day so they could catch it early if there was something wrong with the softener...” She stated she had not noticed on the Water System Logs the testing was being done at the incorrect times.”