VCU Medical 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: 42042 Based on observations, document review, and interview, it was determined staff failed to perform hand hygiene in between glove changes for two (2) of three (3) patients observed. The findings include: On 06/05/24 at 7:45 am, the surveyor initiated treatment floor observations. On 06/05/24 at 8:32 am, the surveyor observed Staff Member #4 briefly leave dialysis station #2 during central venous catheter (CVC) dressing change of Patient #2 to retrieve alcohol wipes from the clean supply cart following the removal of gloves. The same staff member then returned to the treatment area to don new gloves without performing hand hygiene in between. On 06/05/24 at 11:28 am, the surveyor observed Staff Member #3 discard a used syringe and needle into the biohazard sharps bin while caring for Patient #1 at dialysis station #1. The same staff member was observed removing dirty gloves and donning new gloves without performing hand hygiene in between. On 06/05/24 at 9:19 am, the surveyor interviewed Staff Member #22 who confirmed that hand hygiene practices--via “soap and water” washing or alcohol-based hand rub--should be performed in between glove changes. In the afternoon of 06/05/24, the surveyor reviewed the facility’s “Hand Hygiene” policy (effective date: 11/07/23). On page three (3) of five (5), the policy stated that hand hygiene is indicated following removal of gloves and prior to donning new gloves.”

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 42042 Based on document review and interview, it was determined the facility failed to screen all patients for tuberculosis for four (4) of four (4) patients. The findings include: On 06/04/24 at 3:09 pm, the surveyor initiated medical record review of Patient # (1-4) with the assistance of both Staff Member #21 and Staff Member #22. During review, the surveyor requested the immunization information of all four (4) patients. Staff Member #22 shared documentation surrounding Pneumococcal, Hepatitis B, Influenza immunization history. The surveyor did not observe any documentation related to patients being screened for Tuberculosis (TB). Staff Member #22 confirmed that TB screening documentation could not be found for Patient # (1-4). On 06/05/24 at 8:30 am, the surveyor was provided by Staff Member #22 the facility document titled, “Immunization and Screening in Acute and Chronic Hemodialysis Policy” (effective date: 10/2021). The policy outlined the facility’s guidelines for vaccination and screening of dialysis patients for Influenza, Pneumococcal, Hepatitis B, and Hepatitis C. The policy stated that nursing staff are to collect and document immunization history on “every patient” within the immunization record of the EMR (electronic medical record) and should include whether the patient has been screened for Tuberculosis (TB). On 06/05/24 at 9:13 am, the surveyor conducted additional interview with Staff Member #22 who confirmed that hemodialysis patients on unit are not typically screened for TB to include either tuberculin skin test (TST) or TB questionnaire.”

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 42042 Based on document review and interview, it was determined the facility failed to ensure staff had active Cardiopulmonary Resuscitation (CPR) certifications for one (1) of five (5) staff reviewed. The findings include: On 06/05/24 at approximately 10:00 am, the surveyor reviewed the personnel files of Staff Member #5, Staff Member #8, Staff Member #21, Staff Member #23, and Staff Member #24 with the assistance of both the Employee Health and Human Resources teams. During review of Staff Member #8, the surveyor received verbal confirmation from Staff Member #26 that the employee’s CPR certification had expired. The surveyor was supplied Staff Member #8’s CPR certification for the Basic Life Support (BLS) Provider which stated, “Renew by 02/2024”. The surveyor confirmed there was no other more recent CPR documentation for the employee. During personnel review, Staff Member #1 stated that the facility did not have an associated policy surrounding staff CPR certifications. Staff Member #1 added that the employee’s associated job description should therefore be referred to. The surveyor was provided a job description for the role of Staff Member #8 which confirmed that active BLS Certification from the American Heart Association (AHA) was required.”