Fmc Sevierville

“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: 51389 Based on facility policy review, observation and interview, the facility failed to ensure hand hygiene to prevent the spread of potentially infectious bacteria for 8 observations during patient care out of 25 observations made. The findings include: Review of the facility policy, “Hand Hygiene,” dated 11/6/2023, revealed “The purpose of this policy is to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination...hands will be...decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water...before and after direct contact with patients...entering and leaving the treatment area...before performing any invasive procedure such as vascular access cannulation or administration of parenteral medications...immediately after removing gloves...after contact with inanimate objects near the patient...when moving from a contaminated body site to a clean body site on the same patient...after contact with the dialysis wall box, concentrate, drain, or water lines...after contact with other objects within the patient station or treatment space...Alcohol based hand rubs dispensers should be strategically placed throughout the facility...Patients should perform hand hygiene...prior to and after each dialysis treatment...” During a continuous observation on 8/4/2025 at 10:05 AM, Pt (patient) #11 entered the treatment area, obtained his weight, walked to his dialysis station without sanitizing his hands. During a continuous observation on 8/4/2025 at 10:15 AM, PCT (Patient Care Technician) #1 placed a blood pressure cuff on Pt #4, proceeded to touch the dialysis machine to type in information, and returned to assist Pt #4 with bare hands, all without donning gloves. During an observation on 8/4/2025 at 10:25 AM, PCT #1 touched Pt #5’s dialysis machine wearing gloves. Continued observation revealed PCT #1 proceeded to Pt #10’s dialysis station, touched the dialysis machine without removing the dirty gloves, sanitizing, or donning new gloves. During an observation on 8/4/2025 at 11:15 AM, PCT #2 touched Pt #11’s dialysis machine with bare hands, not donning a pair of gloves. During a continuous observation on 8/4/2025 at 11:25 AM, PCT #2 touched Pt #10’s dialysis machine without wearing gloves. Continued observation revealed PCT #2 continued, without sanitizing hands, to gather clean supplies and dialysis needles from a general supply area in the nurse’s station. Further observation showed PCT #2 continued with dirty hands to open the sterile needle packs and placed syringes on the end of the dialysis needles without sanitizing hands and donning gloves. During an observation on 8/4/2025 at 11:40 AM, PCT #1 touched Pt #4’s dialysis machine wearing gloves. Continued observation revealed PCT #1 contiued to Pt #10’s dialysis station and touched the dialysis machine without removing the dirty gloves, sanitizing, or donning new gloves. During an observation on 8/4/2025 at 3:45 PM, Pt #12 held a pressure dressing with a gloved hand, over his access site, after the dialysis needle was removed (to assist in stopping bleeding). Continued observation revealed when Pt #12 was finished holding the pressure dressing and removed his glove, he did not sanitize his hands before he exited the treatment area. During an observation on 8/4/2025 at 4:00 PM, Pt #10 held his pressure dressing with a gloved hand, over his access site, after the dialysis needle was removed (to assist in stopping bleeding). Continued observation revealed when Pt #10 was finished holding the pressure dressing and removed his glove, he did not sanitize his hands before he exited the treatment area. During an interview on 8/6/2025 at 11:20 AM, the Clinical Manager confirmed the staff must sanitize their hands and wear gloves when they are touching a machine or a patient, “...The staff must remove their gloves and wash their hands and place new gloves between patients.” Continued interview confirmed the patients should be washing their hands in the sink or using hand sanitizer after holding their access site and before leaving the clinic. The Clinical Manager confirmed the observations shared did not follow the Hand Hygiene policy.”