University Dialysis West

“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: 37913 Based on observation, interviews, and policy review, the facility failed to ensure that all medical waste is transported in a manner to prevent contamination of other surfaces or persons. This deficient practice could affect all 150 patients at the facility. Findings include: During an observation on 02/26/24 at 4:15 PM, on the dialysis treatment floor, Patient Care Technician (PCT) 2 removed contaminated dialysis lines at end of treatment from Station 19. PCT2 Then carried the contaminated dialysis lines 23 feet past (Distance was measured counting the number of 12 inch by 12 inch floor tiles from station 18 to the biohazard waste container) patients sitting at Stations, 18 and 23 to dispose of the dialysis lines in a biohazard waste container that was across from Station 17. During an interview on 02/26/24 at 4:20 PM, PCT 2 was asked how should contaminated dialysis lines be handled. PCT 2 stated that “I should have brought the biohazard container over to Station 19 and not walked the contaminated dialysis lines past patient sitting at Stations 18 and 23. On 02/26/24 at 4:30 PM with the Nurse manager was asked should contaminated dialysis lines be carried past patient sitting in their dialysis chairs? He/she stated that “The biohazard waste can should be brought to the station that is being cleaned and dialysis lines should not be carried past patient receiving dialysis, there is a potential to contaminate other patients.” Review of the facility’s policy titled “Biologically hazardous (Biohazard) material disposal” effective date: 06/2011, revealed, “All persons who dispose of biohazardous material will take precautions to protect patients, visitors, themselves and staff members form hazards associated with the material.””

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 37913 Based on observation, staff interview, and review of manufacturer’s instructions, the facility staff failed to ensure expired medications were not available for use during one of three survey days. The failure to remove expired medications could have resulted in staff using medications that were expired and or not effective and could affect 150 in-center patients. Findings include: Observation on 02/26/24 at 9:30 AM revealed that an open vial of tuberculin purified protein derivative (Serial Number 3CA04C1) was in the medication refrigerator and was labeled with the date it was opened 01/17/24 and a expiration date of 02/14/24. During an interview on 02/26/24 at 9:50 AM, Floor Supervisor stated, “the bottle of Tuberculin Purified protein derivative should have been discarded after 30 days.” Review of the manufacturer’s instructions on the container of Tuberculin Purified Protein stated, “Once the Tuberculin Purified protein derivative was open it needed to be discarded within 30 days.” Review of the facility’s policy titled, “Medication Administration,” effective date 08/09/22, section, “Entry of multiple-dose EPO/Retacrit/Zemplar Vials” states in part, “All other multi-dose (MD) vials should be discarded per UHS policy (28 days from first entry or expiration date whichever comes sooner.””