Usrc Fort Worth

“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: 48653 Based on observation, record review, and staff interview, the facility staff failed to change gloves and perform hand hygiene between patient encounters (Patient # 22 and # 23) and before touching dialysis equipment. Findings Include: During a tour of the facility’s in-center treatment area with Staff # 1 on 06/04/2024 at 11:00 AM, the surveyor observed Staff # 17 don a pair of gloves. Staff # 17 did not perform hand hygiene before donning the pair of gloves. Staff # 17 proceeded to Patient # 22’s dialysis station and was observed touching the machine and dialysis lines and touching the patient’s access with the same pair of gloves on. Staff # 17 then proceeded to Patient # 23’s station due to the machine alarming. The same gloves were worn to care for two different patients. Staff # 17 did not change gloves or perform hand hygiene between patient encounters or between contact with the machine and the patient. A review of the facility’s policy, “Infection Control and Precautions for All Patients” with a revision date of 07/2023 revealed, “PURPOSE: To educate staff on general guidelines in the prevention of infection within the dialysis facility. PROCEDURE: ... 10. Hand Hygiene: a. Patient and visitors must perform hand hygiene before and after entering patient treatment area and after the removcal of PPE, if applicable. If patient is unable to perform independently, staff will assist the patient. b. Staff will perform hand hygiene: i. Using soap and water or antibacterial hand sanitizer before/after all patient contact and before donning and after doffing PPE, including gloves. ii. After contact with integrated keyboard or chairside computer, regardless of whether contact occurred through gloved or ungloved hands. 11. Personal Protective Equipment (PPE): a. Staff MUST remove gloves and perform hand hygiene between each patient or station ....” During an interview with Staff # 1 on 06/04/2024 at 2:30 PM, Staff # 1 acknowledged the staff member did not follow the facility policy in regard to changing gloves and performing hand hygiene at the appropriate intervals.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interview, the facility staff failed to ensure medications maintained in the facility were properly safeguarded and not accessible to unauthorized persons in 1 of 1 medication cabinets on the in-center treatment area. During a tour of the facility’s in-center treatment area on 06/04/2024 at 11:30 AM, the surveyor observed one medication syringe labeled as “heparin” with Patient # 21’s identification affixed to it. The medication syringe was in an unlocked cabinet at the nurses’ station. The cabinet at the nurse’s station containing medications and other supplies such as lab tubes and saline syringes was unlocked and accessible to unauthorized persons. A review of the facility’s policy, “Guidelines for Administration of Medication” with a revision date of 04/2024 revealed, “PURPOSE: TO maintain the safety and comfort of the patient with regard to the administration of a medication and to administer medications in accordance with a physician’s order and protocol where applicable, per state and federal regulations according to the following procedure, PROCEDURE: 1. Medications administered to patients will have a written, verbal/telephone or electronic order by a physician/advanced practice provider (APP) duly licensed to prescribe medications .... 8. The charge nurse is responsible for the security of medications. During the charge nurse absence from the treatment floor, the security of the medications will only be delegated to a nurse until charge nurse returns. a. Medications will be secured in a locked cabinet except for the emergency medication supply which is kept in an emergency medication box or the facility emergency cart and will be secured with a locking tag to ensure the safety of these medications ...” During an interview with Staff # 1 on 06/04/2024 at 11:30 AM, Staff # 1 acknowledged the medications were unsecured and accessible to unauthorized persons.”

“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: 48653 Based on observation, record review, and staff interview, the facility staff failed to demonstrate standard infection control precautions through the cleaning and disinfection of contaminated surfaces and equipment within the in-center treatment area. This deficient practice had the likelihood to cause harm to patients, staff members, and the public by increasing the risk of transmission of infectious agents within the facility. Findings include: During a tour of the facility’s in-center treatment area with Staff # 1 on 06/04/2024 at 10:00 AM, the surveyor observed the following infection control issues, Staff # 18 was observed cleaning a dialysis station after a patient completed treatment. Staff # 18 did not allow adequate disinfectant drying time as the manufacturer recommended. Staff # 18 disinfected the dialysis recliner, and the surveyor observed the staff member close the wings on the patient recliner while they were still wet with disinfectant. The manufacturer’s guidance for the disinfection of an item should be followed including appropriate dilution and contact time. A container used for storing diluted bleach water was found to have a black residue on the inside of the container. The diluted bleach water is used in the dialysis in-center treatment area to disinfect clamps (a device used to provide consistent pressure to stop bleeding). There were dialysis clamps stored inside the container which had a build-up of black substance. The surveyor observed multiple blood pressure cuffs with a build-up of unknown particles and other debris on the Velcro portion of the cuff. The surveyor observed multiple wall boxes (Station # 19, #20, and #30) with a build-up of acid and bicarb splatter inside of them and on the wall surrounding the wall boxes. The wall boxes are to be cleaned and disinfected at the end of each patient treatment according to facility policy. There were two areas where the particle board was exposed and could not be properly cleaned and disinfected due to damaged laminate. The dirty sink located behind a dialysis station had a large area of particle board exposed and the sink had been damaged, causing it to be unlevel. The section of laminate on the wall behind the patient station was damaged and peeling off. The particle board was exposed and could not be disinfected. A review of the facility’s policy, “Disinfection and Cleaning of Dialysis Machine Equipment” with a revision date of 07/2023 revealed, “PURPOSE: To provide guidance on proper disinfection of the dialysis station, machine, equipment, and surrounding surfaces with the appropriate method prevent the transmission of disease/infection to the dialysis population. POLICY: 1. A 1:100 dilution bleach solution will be made daily or per stricter state regulations and discarded at the end of the day. 2. Label the bleach container with concentration, date, time and initials of individual mixing the bleach solution. Both container and lid must be opaque to prevent weakening of the bleach solution. Container will remain covered at all times. 3. The bleach solution will have at least a five (5) minute contact time as per manufacturer’s recommendation for external disinfection of non-disposable items, dialysis machines, dialysis chairs and related surfaces. 4. Complete surface disinfection at the end of each dialysis treatment after the patient has vacated the station. DISINFECTION PROCEDURE: 1. Don full PPE. 2. Follow manufacturer’s instructions for disinfection of the dialysis machine, chair and related equipment. Follow instructions for appropriate disinfectant and appropriate contact lime. 3. After each treatment, remove bloodlines and disposable supplies. Clamps will be removed from the IV pole and disinfected even if not used on the patient. 4. Empty the prime container into a designated dirty sink. Do not empty contents of the prime container in the wall box. 5. Remove gloves, perform hand hygiene, don clean gloves. 6. Obtain at least one (1) clean moistened 1:100 bleach cloth for the machine, one (1) for the chair and one (1) for ancillary equipment (oxygen concentrator/acid jug/TV/TV remote). NOTE: If patient is not sufficiently stable to be moved from the dialysis station, cleaning and disinfection of equipment at the station and preparation for next patient will be delayed until patient can be safely moved outside the station. 7. Clean all external surfaces of the dialysis machine to include top, sides, front and back, BP cuffs and basket; dialysate connectors and lines; hand sanitizer and holder; IV pole, items hanging on pole, attached computer monitors and keyboard/mouse. 8. Disinfect all surfaces of the prime waste container, inside and out, with a moistened 1:100 bleach cloth. 9. Clean counter tops behind patient station. 10. Clean ancillary equipment including but not limited to: oxygen concentrator; acid/bicarb jug (ifapplicable); IV pole/pump (if applicable), emergency cart, AED and suction machine. 11. Clean chair by placing in the reclining position and swing arms out (if applicable) to clean seat, footrest, backrest and sides, armrest, inside of chair arms and chair frame and side tray tables. Return chair to its upright position when cleaning is complete. 12. Visible blood: Utilize a two-step process to clean and disinfect. a. First use a moistened 1:100 bleach cloth to remove the blood; b. Then use a second moistened 1:100 bleach cloth to disinfect the surface. 13. Adhere to appropriate contact time between external disinfection of the machine/chair and set up for the next patient. NOTE: Do not leave wet cleaning/disinfecting agents on B Braun machine monitors. If necessary, use a dry cloth after 5-minute contact time. 14. Clean chairside computer keyboards, computer on wheels (COW), external surfaces of computer stations and wall boxes with individual 1:100 bleach wipes at the end of the day. To prevent any cross contamination, change gloves and perform hand hygiene any time the wall box is touched. Examples: When connecting/disconnecting dialysate lines and after disinfecting the wall box. 15. Disinfect non-disposable medical equipment (e.g., scissors, hemostats in open position and clamps), between uses by fully submerging items and soaking in a 1 :100 bleach solution for at least 5 minutes. a. If an item is visibly soiled, clean with a wet 1:100 bleach cloth prior to submerging in bleach solution. b. After at least a 5-minute contact time, remove items, place in a clean container or on a clean pad and allow to air dry. 16. Place all non-disposable medical equipment in a designated clean area for storage. 17. Internal disinfection of the dialysis machine will be per the technical policy. NOTE: Internal disinfection of the machine can be initiated prior to patient vacating the station. 18. When treating COVID-19 positive patients, thoroughly clean lobby, patient restrooms and all common patient areas after patient vacates each area, no less than after each dialysis shift and at end of day (e.g. performed by facility staff in addition to janitorial personnel) ....” During an interview with Staff # 1 on 06/04/2024 at 11:00 AM, Staff # 1 confirmed the facility’s in-center treatment area infection control issues.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 48653 Based on observation, policy review, and staff interview, the facility staff failed to ensure 1 of 3 emergency pull cords(a call light strategically placed throughout the facility to provide a user with a convenient means of summoning help in an emergency) was accessible for a patient in the event of an emergency. The emergency pull cord should be within 6 inches of the floor, hanging freely, and accessible to patients. Upon entering the facility’s lobby on 06/04/2024 at 9:30 AM, the surveyor observed the emergency pull cord inaccessible and blocked by multiple chairs. A review of the facility’s policy, “Facility Safety Requirements” with a revision date of 04/2023 revealed, “PURPOSE: Facilities will provide a physical environment that protects the health and safety of patients, staff, and the public. The surrounding areas that are used by patients (e.g., stairwells, corridors, passageways) will meet local building and fire safety codes relating to design and space requirements for safe access, ingress, egress, and patient safety. POLICY: 9. An emergency call system will exist in patient areas (e.g. patient restroom) that will be accessible to a patient lying on the floor. State-specific regulations may require call systems outside of the treatment area and will be accessible as required by those regulations ...” In an interview with Staff #1 on 06/04/2024 at 9:30 AM, Staff # 1 acknowledged the pull cord was blocked and inaccessible to patients in the event of an emergency.”