Clear Lake Kidney 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: 17991 Based on observations, interviews, and policy review, 1.) Two of two patients (P) (P8, and P9) failed to remove gloves and sanitize hands after holding needle access sites, and 2.) Two of two staff (Patient Care Technician (PCT) 3 and PCT 4) caring for P8 and P9 failed to encourage them to wash and/or sanitize their hands after removing gloves. These failed infection control practices place all 69 incenter patients, staff, and the community at risk for transmission of blood-borne pathogens and/or other microorganisms. Findings include: 1. During an observation on 03/05/24 at 9:35 AM, P9 was observed holding his/her access site with a gloved hand, waiting for the site to clot. P9 removed the glove, gathered up personal items, and walked to the scale. P9’s access site began to bleed so he/she with bare hand applied pressure and proceeded to return to the dialysis station. PCT 4 assisted the patient to apply a new glove and stop the bleeding. P9 once again removed the glove and proceeded to the scale. PCT 4 failed to direct P9 to the sink or encourage him/her to sanitize hands before leaving the treatment floor. During an interview on 03/05/24 at 10:01 AM, PCT 4 said he/she told P9 to wash his/her hands and P9 may have used the lobby bathroom to wash hands before leaving. 2. During an observation on 03/05/24 at 10:25 AM, P8 was observed holding his/her access site with a gloved hand, waiting for the site to clot. P8 removed the glove, gathered up personal items, and walked to the scale. PCT 3 failed to encourage P8 to sanitize hands after removing the glove and before gathering up personal items. During an interview on 03/05/2024 at 10:25 AM, PCT 3 confirmed that P8 should sanitize his/her hands immediately after removing the glove and before touching his/her personal items. A review of the facility’s policy titled “Hand Hygiene,” dated 11/06/23, indicated “All staff, patients ...must follow the same requirement for hand hygiene ...The table below identifies when hands shall be washed specifically with soap and water or when alcohol-based rubs can be used ...Hands Will Be ...Washed with Antimicrobial soap and water When ...Hands are visibly dirty or contaminated with ...blood ...Decontaminated using alcohol-based hand rub ... Immediately after removing gloves ...Hand Hygiene: Patients ...Gloves must be provided to patients when performing procedures which risk exposure to blood ...such as when ...holding access sites ...To help ensure the prevention of cross contamination to their family member or other patients, hand hygiene must be performed.””

“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: 17991 Based on observation, interview, and policy review, the facility failed to ensure two of two staff (Patient Care Technician (PCT) 2, Registered Nurse (RN) 2) emptied and disinfected prime waste receptacles (a bucket on the side of the dialysis machine which has a potential to be contaminated with bloodborne pathogens) between patient’s dialysis treatments. This failure placed all 69 in-center dialysis patients at risk for illness and or infection from bloodborne pathogens and/or other microorganisms. Findings include: During an observation on 03/04/24 at 10:00 AM, PCT 2 disinfected dialysis Station #4 after the patient had completed the treatment. PCT 2 failed to empty and disinfect the prime waste bucket. During an interview on 03/04/24 at 10:15 AM, PCT2 confirmed he/she had failed to empty and disinfect the prime waste bucket. During an observation on 03/04/24 at 11:35 AM, RN2 disinfected dialysis Station #7 after the patient had completed the treatment. RN2 failed to empty and disinfect the prime waste bucket. During an interview on 03/04/24 at 11:45 AM, RN2 confirmed he/she had failed to empty and disinfect the prime bucket. A review of the “Clinic Audit Checklist” (observation audits) completed by in-center staff, dated 11/13/23 and 02/07/24, titled “Cleaning and Disinfection of the Dialysis Station,” indicated RN1 and RN3 had failed to empty and disinfect the prime waste bucket between patients. A review of the facility’s policy titled “Use of Priming Buckets,” dated 01/24/24, indicated, ...”4. At the completion of the patient treatment, remove the priming bucket or approved removable container, and dispose of the Normal Saline in the utility room hopper or dirty sink ...5. After routine surface disinfect with 1:100 bleach solution, replace on machine.””