Davita Willowbrook 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: 10802 Based on observation, interview and record review facility’s direct staff failed to remove contaminated gloves and wash/ sanitize contaminated hands prior to gloving and providing care and services to patients in 2 of 6 staff observed; Patient Care Technician (C) and Patient Care Technician (K) Findings: Review of the facility’s current policy and procedure on infection control for dialysis facilities; Policy #1-05-01 ;revised April 2023 directs staff as follows: “HAND HYGIENE 1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, e. after interacting with wall boxes (i.e., plugging/unplugging acid/bicarb lines form dialysis machine, changing acid types, when exchanging a dialysis machine) f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. 2. Patients and caregivers will be encouraged to a. Wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis. b. Perform hand hygiene after treatment before leaving treatment area.” Patient Care Technician (C) On 06/20/2024 at 6:28 a.m. Patient Care Technician (C) was observed at station # 2 on the unit. The patient care technician was initiating hemodialysis treatment on patient #2. Observation revealed during initiation of the patient’s hemodialysis treatment the telephone at the nurses’ station rang consistently. There was no administrative assistant present in the facility to answer the telephone. Patient Care Technician stopped providing care to the patient, removed her contaminated gloves, answered the telephone, returned to the station, and reset the patient’s hemodialysis and blood lines with her contaminated hands. Patient Care Technician (K) On 06/20/2024 at 10:59 a.m. Patient Care Technician (K) was observed on the unit preparing the station for an oncoming patient. While walking to obtain supplies to terminally clean the station, Patient Care Technician (K) picked up a piece of trash off the floor of the unit with her ungloved hand. After picking up the trash she did not wash or sanitize her contaminated hands. Patient Care Technician (K) walked to the area where the clean towels, gloves and bleach are stored and picked up clean gloves from the box of gloves with her contaminated hands. The Surveyor immediately notified her of the break in infection control of her not washing or sanitizing her contaminated hands. Patient Care Technician (K) states “I am sorry I was not thinking.””

“MICROB MONITOR-MO H20 SAMPLES/METHOD CFR(s): 494.40(a) 7.2 Microbial monitoring methods: monthly water samples/method 7.2.1 General Culture water ...weekly for new systems until a pattern has been established. For established systems, culture monthly unless a greater frequency is dictated by historical data at a given institution. Monitoring can be accomplished by direct plate counts, in conjunction with the measurement of bacterial endotoxin. 7.2.2 Sample collection Water samples should be collected directly from outlet taps situated in different parts of the water distribution system. In general, the sample taps should be opened and the water should be allowed to run for at least 60 seconds before a sample is collected in a sterile, endotoxin-free container. A minimum of 50 mL of water, or the volume specified by the laboratory performing the test, should be collected. Sample taps should not be disinfected. This Standard is not met as evidenced by: 10802 Based on observation, interview and record review, the facility failed to ensure 4 consecutive weeks of cultures were done after installation of a new water system. Findings: Review of the facility’s current policy and procedure on Microbial Validation of Facility Water Treatment Systems after Installation. Policy # 2-06-05, revised March 2015 directs staff as follows: “Water sample for bacteria and endotoxin will be collected at a minimum: Step One (1) Perform three (3) consecutive days following installation of system. If all samples meet acceptable limits proceed to step two (2). If any sample (s) results are at or above action, meet acceptable limits proceed to step (20 n level, disinfect system and repeat sample (s) from step one (1) If repeat sample (s) from step two (1), meet acceptable limits proceed to step two (2). If any repeat sample (s) from step (2) are at or above action level after disinfection, Follow the --- policy : Troubleshooting -Elevated Bacteria/ Endotoxin Policy. Step two (2) :after successful completion of step one (1) the facility may proceed to use the water treatment system for patient use. Samples will be obtained once a week for three (3) additional weeks.” Observation On 06/20//2024 at 8:30 a.m. of the facility’s water treatment room revealed a Braun Aqua bar NX water purification system along with two new carbon tanks, a softener tank and acid holding and mixing tank. Interview with (facility’s) biomedical technician revealed a new water system was installed in the facility.” The Surveyor requested documentation of cultures and endotoxin drawn since installation of the system. The facility’s biomedical technician provided to the Surveyor three sets of cultures drawn on 06/03/2024, 06/04/2024 and 06/05/2024 of the reverse osmosis of product water out. Interview on 06/20/2024 with the Facility’s Area Biomedical Technician revealed he said the water treatment room was gutted and an entire new system installed. He said there has been some confusion doing three days of cultures instead of four consecutive week of cultures. He said there was a problem with the reverse osmosis system, but it was corrected on 6/13/2024 and cultures were not drawn since then.”

“GOV-GB RESP FOR STAFF ORIENTATION CFR(s): 494.180(b)(3) The governing body or designated person responsible must ensure that- (3) All staff, including the medical director, have appropriate orientation to the facility and their work responsibilities; This Standard is not met as evidenced by: 10802 Based on observation, and interview, facility’s governing body failed to provide orientation to 1 of 1 visiting staff observed providing care and services to patient in the facility: Registered Nurse (J) Findings: On 6/20/2024 at 10:46 a.m. Registered Nurse (J) was observed on the treatment floor of the facility at station # 1. The registered nurse was providing central venous catheter care to patient #4 for initiation of hemodialysis treatment on the patient. Observation revealed the patient with a central venous catheter in place which is used for hemodialysis treatment. Observation revealed Registered Nurse (J) picked up her face shield and donned it, touching her hair while putting on the face shield. The registered nurse then picked up a clean pair of gloves from the glove box stored near the station with her contaminated hands, and proceeded to provide central venous catheter care to the patient. The registered nurse did not wash or sanitized her contaminated hands prior to gloving and providing care to the patient. After providing care to the patient, the registered nurse walked around the unit with blue clamps in her hands asking staff where to soak the clamps. Interview with Registered Nurse (J) revealed the Surveyor asked Registered Nurse (J) if she had orientation to the unit, she states “ This is my first time here, I work at another facility and I did not have orientation here”. The Surveyor Immediately notified the Facility’s Administrator of her observation. and requested documentation of the nurse’s training and orientation. None was provided. The Facility’s Administrator confirmed that Registered Nurse (J) did not have orientation to the unit prior to providing care to patients.”