Dci Henderson

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 49570 Based on facility policy review, observation and interview, the facility failed to ensure expired supplies were not available for use in 2 of 2 (supply storage and lab) supply storage areas observed. The findings included: 1. Review of facility policy “Work Day Inventory Policy” revised January 2025 revealed, “...1. When performing inventory counts, expiration dates will be monitored, and appropriate staff notified when approaching expiration date so that stock can be replenished... 2. Expired stock should not be available for use and should be discarded ...” 2. Observations on 2/3/2025 at 9:25 AM in supply storage revealed one (1) unopened bottle of hand sanitizer with an expiration date of 9/2023. Observations on 2/3/2025 at 9:25 AM in supply storage revealed one (1) unopened protein shake with an expiration date of 10/1/2024. During an interview on 2/3/2025 at 9:27 AM, the NM confirmed the above supplies were expired. 3. Observations on 2/3/2025 at 9:27 AM in the lab revealed forty-four (44) S-monovette 92x15mm lab supplies with an expiration date of 3/31/2023. During an interview on 2/3/2025 at 9:27 AM, the NM confirmed the lab supplies were expired.”

“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: 49570 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 3 (RN#1 and the NM) staff observed on the treatment floor. The findings included: 1. Review of the facility’s policy titled, “Hand Antisepsis” dated August 2014 revealed, “...Hand Antisepsis will be followed per CDC guidelines...Use of an alcohol-based rub may be done in the following instances...After handling of equipment, supplies, or environmental surfaces at the patient station. Before patient contact. Before putting on gloves...After removal of gloves...” 2. Observations on 2/3/2025 at 9:42 AM on the treatment floor at Station #10, revealed RN #1 disinfecting the dialysis station. RN #1 failed to remove her gloves and perform hand hygiene after emptying and cleaning the inside and outside of the prime waste bucket and continued to disinfect the dialysis machine. Observations on 2/3/2025 at 10:40 AM on the treatment floor at Station #12, revealed RN #1 disinfecting the dialysis station. RN #1 failed to remove her gloves and perform hand hygiene after cleaning the inside and outside of the prime waste bucket, and before completing the procedure. During an interview on 2/3/2025 at 2:42 PM, the NM was asked if staff should remove gloves and perform hand hygiene after cleaning the prime waste container. The NM stated, “that [prime waste container] would be considered part of the machine so I wouldn’t.” 3. Observations on 2/3/2025 at 11:42 AM on the treatment floor at Station #10, revealed RN #1 performing CVC exit site care on RP #1. RN #1 removed gloves, performed hand hygiene, then opened the supply cabinet to obtain a betadine swab. Without performing hand hygiene, the RN donned new gloves and cleaned the exit site. RN #1 removed the gloves, performed hand hygiene, then opened the supply cabinet to obtain a sterile dressing. Without performing hand hygiene, the RN donned new gloves, opened the dressing and applied it to the exit site. During an interview on 2/4/2025 at 2:42 PM, the NM verified RN #1 should have performed hand hygiene after opening the supply cabinet and before donning new gloves.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 49570 Based on facility policy review, observation, and interview the facility failed to ensure dialysis stations were fully disinfected between patients by 1 of 2 (PCT #1) staff members observed. The findings included: 1. Review of the facility policy titled, “Standard Practices for Hemodialysis Units” last revised January 2025 revealed, “...Clean and disinfect the dialysis station (e.g., chairs, beds, tables, machines) between patients... Clean the tops of machines... Clean the entire station (chair/machine/ancillary equipment)... with a 1% bleach solution of bleach and water ...” 2. Observations on 2/3/2025 at 10:54 AM revealed PCT #1 disinfecting Station #12. PCT #1 failed to clean the dialysis hoses on the front of the machine. During an interview on 2/3/2025 at 2:42 PM, the NM stated staff were expected to clean the fronts, sides and top of the machine, behind the machine and the hoses and connectors behind it. When asked if staff should clean the dialysis hoses on the front of the machine, the NM stated, “We haven’t been cleaning the hoses.””

“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: 49570 Based on facility policy review, observation, and interview, the facility failed to ensure measures to prevent CVC related infections were followed by 2 of 2 (NM and RN #1) nurses observed performing direct patient care to patients with CVCs. The findings included: 1. Review of the facility’s policy titled, “CVC: Accessing with Closed System Connections” revised 10/2018 revealed, “...Closed system connectors are attached to both the arterial and venous hubs of the CVC. These connectors are left in place during hemodialysis and also throughout the next week... Closed system connectors must be changed every seven days... Whenever the closed system connector is used, a minimum 15 second alcohol pad scrub to the end of the connector is required...Procedure...Place barrier pad underneath CVC lumens 8. Open closed system connector packages and scrub both hubs with alcohol 15 sec each. 9. Aseptically attach Heparin bolus to one and 10 cc NS flush to the other...Remove bridge tape from port connection 9. Scrub port connection (arterial and venous) with alcohol prep pad; cleanse for minimum of 15 seconds...11. Remove existing caps...12. The catheter ends are now open and exposed, ensure that the CVC is held so that contamination does not occur. 13. Scrub each exterior hubs with new alcohol prep pad for a minimum 15 seconds...Post-treatment...Before detaching blood lines rinseback/treatment termination - remove bridgetape from arterial port, scrub external connection between closed system connector and bloodline...Perform rinse back per policy...Clean both connector ends (arterial and venous) with alcohol prep pad; 15 second scrub...Discard gloves; sanitize hands...” 2. Observations on 2/3/2025 at 9:28 AM on the treatment floor at Station #4 revealed the NM discontinuing dialysis on RP #3. The NM failed to scrub the closed system connectors for a minimum of 15 seconds per facility policy after disconnecting the blood lines and prior to connecting the sterile syringes. 3. Observations on 2/3/2025 at 10:00 AM on the treatment floor at Station #4 revealed the NM initiating dialysis on RP #2. The NM failed to scrub the closed system connectors for a minimum of 15 seconds per facility policy before and after disconnecting the blood lines, prior to connecting the sterile syringes, before and after changing out the closed system connectors. Further observations revealed the NM removed the closed system connector from the venous and arterial limb and laid both uncapped catheter hubs directly on the moisture proof barrier leaving them open to air before reconnecting new closed system connectors. The NM failed to hold the uncapped catheter hubs to prevent contamination and failed to scrub the hub for 15 seconds per facility policy prior to putting the new closed system connector in place and before/after treatment. 4. Observations on 2/3/2025 at 11:51 AM on the treatment floor at Station #10, revealed RN #1 performing closed system connector change on RP #1’s CVC. After removing the closed system connector from the venous limb, RN #1 laid the uncapped catheter hub directly on the moisture proof barrier leaving it open to air. RN #1 removed the gloves, performed hand hygiene, donned new gloves, and scrubbed the venous catheter hub 6 seconds then placed a new closed system connector on the limb. RN #1 failed to hold the uncapped catheter hub to prevent contamination and failed to scrub the hub for 15 seconds per facility policy prior to putting the new closed system connector in place. 5. During an interview on 2/4/2025 at 2:42 PM, the NM verified open catheter hubs should not be placed on the barrier or allowed to touch anything during the procedure. The NM continued and stated the closed system connectors and/or catheter hubs should be scrubbed for at least 15 seconds.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 49570 Based on facility policy review, medical record review, and interview, the facility failed to ensure pre-treatment assessments were completed by a Registered Nurse for 3 of 5 (Patient #2, #3, and #4) sampled hemodialysis patients. The findings included: 1. Review of facility policy, “Initiation of Hemodialysis Treatment for AVF/AVG and CVC” revised 11/10/16, revealed, “ ...RN assessment, along with vital signs (BP, heart rate, temperature, must be completed prior to the initiation of the treatment... RN completes patient pre-assessment ...” Review of facility policy, “Pre-Treatment Patient Assessment” revised 10/25/95 revealed, “...Assessment of the patient pre-treatment is crucial in determining if the patient is stable enough for dialysis and determining the plan of care...3. All patients will be assessed by an RN before the treatment is initiated including mental status, heart sounds, lung sounds, edema, V.S., complaints, and abnormal access findings...” 2. Medical record review for Patient #2 revealed an admission date of 2/7/2022 with diagnoses which included Hypertensive Chronic Kidney Disease and End Stage Renal Disease. Review of a physician’s order dated 9/2/2024 revealed the Patient was to receive hemodialysis treatments 3 times a week. Review of the Hemodialysis Flowsheet dated 1/8/2025, revealed the treatment was initiated at 11:21 AM. There was no documentation Patient #2 was assessed by an RN until 11:41 AM, a total of 20 minutes after the treatment was initiated. Review of the Hemodialysis Flowsheet dated 1/13/2025, revealed the treatment was initiated at 11:20 AM. There was no documentation Patient #2 was assessed by an RN until 12:50 PM, a total of 1 hour and 30 minutes after the treatment was initiated. Review of the Hemodialysis Flowsheet dated 1/15/2025, revealed the treatment was initiated at 11:21 AM. There was no documentation Patient #2 was assessed by an RN until 11:44 AM, a total of 22 minutes after the treatment was initiated. Review of the Hemodialysis Flowsheet dated 1/20/2025, revealed the treatment was initiated at 11:08 AM. There was no documentation Patient #2 was assessed by an RN until 12:27 PM, a total of 1 hour and 19 minutes after the treatment was initiated. Review of the Hemodialysis Flowsheet dated 1/27/2025, revealed the treatment was initiated at 10:55 AM. There was no documentation Patient #2 was assessed by an RN until 12:08 PM, a total of 1 hour and 13 minutes after the treatment was initiated. Review of the Hemodialysis Flowsheet dated 1/29/2025, revealed the treatment was initiated at 11:01 AM. There was no documentation Patient #2 was assessed by an RN until 11:41 AM, a total of 40 minutes after the treatment was initiated. Review of the Hemodialysis Flowsheet dated 1/31/2025, revealed the treatment was initiated at 10:46 AM. There was no documentation Patient #2 was assessed by an RN until 11:50 AM, a total of 1 hour and 4 minutes after the treatment was initiated. 3. Medical record review for Patient #3 revealed an admission date of 10/4/2023 with diagnoses which included Type 2 Diabetes Mellitus with Chronic Kidney Disease. Review of a physician’s order dated 10/11/2023 revealed the Patient was to receive hemodialysis treatments 3 times a week. Review of the Hemodialysis Flowsheet dated 1/20/2025, revealed the treatment was initiated at 11:11 AM. There was no documentation Patient #3 was assessed by an RN until 12:06 PM, a total of 55 minutes after the treatment was initiated. 4. Medical record review for Patient #4 revealed an admission date of 4/19/2024 with diagnoses which included Type 2 Diabetes Mellitus and End Stage Renal Disease. Review of a physician’s order dated 4/19/2024 revealed the Patient was to receive hemodialysis treatments 3 times a week. Review of the Hemodialysis Flowsheet dated 1/20/2025, revealed the treatment was initiated at 12:02 AM. There was no documentation Patient #4 was assessed by an RN until 12:46 PM, a total of 44 minutes after the treatment was initiated. During an interview on 2/4/2025 at 2:40 PM, the NM verified the pre-assessments were not documented until after treatment started on Patient #2, #3, and #4.”

“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: 49570 Based on facility policy review, observation, and interview, the facility failed to ensure measures to prevent exposure of potential infectious bacteria during cannulation of an AVF were followed by 2 of 2 (PCT #1 and the NM) staff observed providing direct patient care on the treatment floor and failed to ensure physical assessment of the access was completed to determine if access could be safely used. The findings included: 1. Review of facility policy, “AV Fistula and Graft Cannulation” revised 8/2022, revealed, “ ...3. Validate that patient has washed access with antibacterial soap and water, nurse assisted if unable. Washing with soap and water before the access is prepped is the first line of infection prevention ...7. Perform physical assessment of the access including patency (thrill or bruit), signs of infection, bleeding or hematoma. Notifies the CN before cannulating if sx infection, inflammation are present to determine if access can be used ...” 2. Observations on the treatment floor on 2/3/2025 at 10:29 AM, revealed the NM initiating treatment on RP #4. The NM failed to auscultate (listen) and feel the access site for patency. 3. Observations on the treatment floor on 2/3/2025 at 11:28 AM, revealed PCT #1 initiating treatment on RP #5. PCT #1 failed to ensure access site was washed with antibacterial soap and water prior to treatment and failed to auscultate the access site for patency. 4. During an interview on 2/4/2025 at 2:40 PM, the NM confirmed that AVG/AVF access sites should be cleansed on-site prior to initiation of treatment and should always be felt and auscultated for patency.”