Davita Northwest Medical Center Dialysis

“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: 22676 Based on observation, interview, and facility policy review, the facility failed to ensure that one of two staff observed (Licensed Vocational Nurse (LVN)9 providing care to patients, used hand sanitizer or washed hands after removing gloves and donning (putting on) new gloves. This deficient practice had the potential to result in increased infections to all 94 incenter patients receiving incenter care at this hemodialysis unit. Findings include: During an observation on the treatment floor on 11/18/24 at 11:05 AM LVN 9 was observed removing gloves and lifting the lid of the bio-hazardous trash can, disposing the gloves and donning new gloves, without using hand sanitizer or washing hands. He/she was then seen initiating treatment on patient (P)12. During an interview with the LVN9 on 11/18/24 at 11:30 PM, he/she confirmed that he/she failed to perform hand hygiene prior to accessing P12’s fistula. During an interview with the Administrator 11/18/24 at 2:00 PM he/she confirmed that staff are supposed to wash their hands or use hand sanitizer after removing gloves and before donning new gloves and providing care to patients. Review of facility policy titled, “Infection Control for Dialysis Facilities” dated 04/23, stated. “All teammates, physicians, and non-Physicians will perform hand hygiene prior to gloving and immediately after removing gloves.””

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should 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. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 22676 Based on observation, interview, and facility policy review, the facility failed to ensure that one of two phoenix meters were cleaned and disinfected prior to returning to the storage area for the next use. This deficient practice had the potential to result in increased infections to all 94 incenter patients receiving incenter care at this hemodialysis unit. Findings include: During an observation on the treatment floor on 11/18/24 at 11:20 AM. Patient Care Technician (PCT)13 was observed using the phoenix meter to test the conductivity of a machine at station 10. PCT13 then returned the phoenix meter to the storage area for the next use without disinfecting the meter. During an interview with PCT13 on 11/18/24 at 12:30 PM, he/she confirmed that he/she failed to disinfect the meter prior to returning it to the storage area. During an interview with the Administrator on 11/18/24 at 1:30 PM he/she confirmed that staff are supposed to disinfect the phoenix meter after use. Review of facility policy titled, “Measuring Conductivity, Temperature Using the Phoenix Meter” dated 4/22 states, “The outside of the phoenix meter must be disinfected after use prior to returning the meter to the storage area.””

“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: 22676 Based on observation, interview, and facility policy review, the facility failed to ensure that one of one staff observed Licensed Vocational Nurse (LVN)8 providing Central Venous Catheter Care (CVC) for two of two (Patients (P)21 and P22) provided the care with infection control maintained. This deficient practice had the potential to result in increased infections to all 94 incenter patients who have the potential to need a CVC for dialysis access. Findings include: 1.During an observation of the CVC connection for P21 on 11/18/24 at 11:25 AM, LVN8 was observed removing the dressing from P21’s CVC. LVN8 then cleaned the CVC site and cleaned down to the (Y) of the CVC and connected the sterile syringes. LVN 8 failed to remove soiled gloves and disinfect his/her hands and don (put on) clean gloves, after removing the soiled dressing and beginning the cleaning of the CVC. LVN8 also failed to scrub each of the hubs prior to connecting the blood lines. 2.During an observation of the CVC connection for P22 on 11/18/24 at 11:55 AM, LVN8 was observed removing the dressing from P22’s CVC. LVN8 then cleaned the CVC site and cleaned down to the (Y) of the CVC and connected the sterile syringes. LVN 8 failed to remove soiled gloves and disinfect his/her hands and don clean gloves, after removing the soiled dressing and beginning the cleaning of the CVC. LVN8 also failed to scrub each of the hubs prior to connecting the blood lines. During an interview with LVN8 on 11/18/24 at 12:15 PM, he/she confirmed the above findings. During an interview with the Administrator on 11/18/24 at 1:30 PM confirmed that staff are supposed to disinfect their hands and don new gloves when moving from dirty to clean during the CVC connection process and are supposed to perform a 15 second scrub to each hub. Review of facility policy titled, “Central Venous Catheter (CVC) with Clear guard Antimicrobial END Caps procedure.” Perform a 15 second scrub of the CVC during the process if connecting or disconnecting the blood lines. 4. Remove old dressing and discard, remove gloves and discard. Perform hand hygiene per procedure and re-glove.””

“BACT CONTROL-DISINFECT 1X/MO/DWELL CFR(s): 494.40(a) 7 Strategies for bacterial control 7.1 General: disinfect monthly/disinfection dwell Routine low-level disinfection of the pipes should be performed to control bacterial contamination of the distribution system. The frequency of disinfection will vary with the design of the system and the extent to which biofilm has already formed in existing systems, but disinfection must be performed at least monthly. A mechanism should be incorporated in the distribution system to ensure that disinfectant does not drain from pipes during the disinfection period. This Standard is not met as evidenced by: 22676 Based on observation, interview, and policy review, the facility failed to ensure that three out of four bottles of “Minncare Residual Test Strips” used for testing for clearance of the Minncare Disinfectant solution after disinfecting the reverse osmosis machine (RO) were not expired. This had the potential to affect all 94 in-center hemodialysis patients receiving care at the facility. Findings include: During an observation in the water room on 11/18/24 at 9:30 AM, revealed three bottles of opened “Minncare Residual Test Strips” manufactures expiration date was 09/22/24. During an interview with the Group Regional Operation Director (GROD) and the Biomedical Technician (Biomed) on 11/18/24 at 9:30 AM, they confirmed the above findings. Review of facility’s policy titled, “Residual Minncare Testing Using Minncare Acid Test Strips” dated 4/21 states, “Verify that strips are not expired.””