Usrc Tri-County Dialysis

“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: 34839 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 toall 71 inventer hemodialysis patients, staff members, and the public by increasing the risk of transmission of infectious agents within the facility. Findings include: Treatment area observations 5/7/25 from 8:51AM until 9:33AM During a tour of the facility’s in-center treatment area with Staff # 1 on 05/07/2025 at 08:55 AM, the surveyor observed the following infection control issues, The surveyor observed 24 out of 24 wall boxes with a build-up of acid and bicarbonate 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. A drawer in the treatment area had an open box of gauze with pens in it. Surveyor asked what the open gauze was for and S#2 stated “It’s for the fistula dressing after treatment.” Surveyor asked “ you don’t use sterile gauze? S#2 stated “No, we only use sterile gauze for the catheters.” Surveyor stated “Well, if this is a clean supply drawer why are you storing dirty pens with the clean supplies?” S#2 removed the pens from the drawer. Staff # 3 was observed setting up machine #9 at dialysis station #9. Surveyor asked S#3 if the station and machine were clean. S#3 responded “yes” . Surveyor noted a white dried substance on top of the dialysis machine, dust behind the machine and white streaks down the right side of the machine as well as a heavy build up of a white substance at the Hanson port. Surveyor donned gloves with S#1 and got 4 disposable bleach clothes, surveyor was able to wipe away the dust and the white substances noted above. Staff # 3 disinfected the dialysis recliner, and the surveyor observed white splatters on the left side of the which the surveyor was able to wipe away. S#3 confirmed the above findings and redirected all staff to disinfect the entire dialysis station. Machine #8 had a heavy build up of a rust colored substance in the Hanson holder. Machine #15 had a heavy build up of a white substance in the Hanson holder. Staff #4 at 9:00AM performed hand sanitization with hand sanitizer and used hand sanitizer to wipe and disinfect stethoscope. Staff #4 at 9:18AM at machine 14 station 6 disconnected patient from dialysis treatment. Staff #4 stethoscope touched patient chair side table while Staff #4 disconnected patient. At 9:22AM Staff #4 performed hand sanitization with hand sanitizer and used hand sanitizer to wipe and disinfect stethoscope. Interview with Staff #1 on 5/7/25 at 9:26AM, surveyor asked what disinfectant is used for stethoscopes between patients. Staff #1 answered “Bleach.” Surveyor said it was observed Staff #4 used hand sanitizer twice to disinfect stethoscope. Staff #1 stated “No, no, they shouldn’t use that.” Policy: Infection Control and Precautions for All Patients Policy # C-IC-0010 Revision Date: 07/2023 Policy reads in part: 13. Supplies: Items taken into the dialysis station will either be disposed of, dedicated for use only on a single patient or cleaned and disinfected before being taken to a common clean area or used on another patient. Treatment area observations 5/7/25 from 8:51AM until 9:33AM. Observation of water treatment room on 5/7/25 from 9:34AM until 9:41AM Findings incluced: Observation in the facility water room 4 of the 5 critic acid jugs with wands were noted to have dust and a dark rust colored build up on the base of the up take wands. At the time of observations, S#5 stated these should be cleaned every week or week and a half. 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 05/07/2025 at 11:00 AM, Staff # 1 confirmed the facility’s in-center treatment area infection control issues and said the staff were being in serviced now and all wall boxes and Hanson holders will be cleaned and disinfected.”