Davita Ripley Dialysis Center

“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 facility 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 4 (RN #1 and PCT #1) staff observed on the treatment floor. The findings included: 1. Review of the facility’s, “Infection Control for Dialysis Facilities” policy 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...” Review of the facility’s “Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure” policy revised October 2024 revealed, “...Perform hand hygiene per procedure...Set up clean field with all appropriate supplies...Place the second moisture proof barrier under catheter limbs...Remove old dressing and discard...Observe site for signs and symptoms of infection...Remove gloves and discard. Perform hand hygiene per procedure and re-glove...clean exit site...” 2. Observations on the treatment floor at Station #10 on 3/17/2025 at 8:57 AM, revealed PCT #1 discontinued hemodialysis treatment via an AVG/AVF for RP #4. The PCT performed hand hygiene, donned gloves, then began the reinfusing process. An alarm went off at Station #12. PCT #1 removed her gloves, donned new gloves without performing hand hygiene, then went to Station #12 and corrected the cause of the alarm. The PCT removed the gloves, donned new gloves without performing hand hygiene, and returned to Station #10 and assessed RP #4’s sitting and standing blood pressure. PCT #1 failed to perform hand hygiene after removing her gloves and between patients repeatedly. During an interview on 3/18/2025 at 1:58 PM, the FA stated hand hygiene should be performed prior to donning gloves, after removing gloves, and between patients. 3. Observations on the treatment floor at Station #9 on 3/17/2025 at 9:44 AM, revealed RN #1 performed exit site care and initiated treatment via a CVC for RP #2. RN #1 performed hand hygiene, donned gloves and removed the old dressing from the CVC exit site. The RN secured the moisture proof barrier to the Patient’s shirt away from the exit site, then proceeded to clean the exit site and lines. After allowing the site to air dry, the RN applied a dressing to the site, then removed his gloves and performed hand hygiene. RN #1 failed to remove his gloves, perform hand hygiene, and don new gloves after removing the old dressing and before cleaning the exit site. During an interview on 3/18/2025 at 1:58 PM, the FA stated, staff should remove their gloves, perform hand hygiene, then don new gloves after removing the CVC dressing and before cleaning the exit site.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 33763 Based on facility policy review, observation, and interview, the facility failed to ensure measures to reduce the risk of infection during cannulation of an AVF and/or AVG prior to initiation of hemodialysis were followed per facility policy by 1 of 2 (LPN #1) staff members observed on the treatment floor. The findings included: 1. Review of the facility’s, “AV Fistula or Graft Cannulation with [Brand Name] or [Brand Name] Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose” policy revised October 2022 revealed, “ ...11. While maintaining aseptic technique, cleanse the site by applying skin antiseptic using a circular rubbing motion, moving from the center out and allow to dry. (For contact and dry time refer to the table above). [TABLE: Skin Antiseptic: Povidone Iodine - Effective Volume: At least 1 prep pad per site or 1 saturated sterile gauze pad per site. - Effective Contact Time: 30 seconds - Air Drying Time: 2 minutes] ...All skin antiseptics work to kill bacteria on the skin and require specific air-dry times ...” 2. Observations on the treatment floor at Station #1 on 03/17/2025 at 9:15 AM, revealed LPN #1 initiated hemodialysis on RP #3 via an AVF/AVG. LPN #1 failed to clean the access site per facility policy by scrubbing the access site with Povidone Iodine/Betadine for twenty seconds instead of thirty seconds per facility policy. 3. During an interview on 03/18/2025 at 1:47 PM, the FA confirmed staff members were expected to follow the facility policy for initiation of dialysis with an AVG/AVF. She stated the Povidone Iodine/Betadine should come into contact with the skin for at least 30 seconds for appropriate cleansing before cannulation is attempted.”