Bma - Russell County

“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: 33906 Based on observations, interviews and document review, it was determined the facility staff failed to follow infection control guidelines by failing to clean the prime waste container after each treatment and/or ensure dialysis stations were appropriately disinfected between patients for three of three observations. The findings were: Observations of care were conducted on 6/17/2025 and 6/18/2025. On 6/17/2025 at 10:38 AM, the surveyor observed a staff member cleaning and disinfecting the vacated dialysis station #4. The staff member failed to clean the sides of the dialysis machine, the laminated documents hanging from the IV pole, the counter behind the dialysis machine and failed to clean the prime waste container. On 6/17/2025 at 11:10 AM, the surveyor observed a staff member cleaning and disinfecting the vacated dialysis station #9. The staff member failed to clean the laminated documents hanging from the IV pole and the counter behind the dialysis machine. On 6/18/25 at 9:22 AM, the surveyor observed a staff member preparing dialysis station #1 for the next patient. The staff noted the prime waste container had not been emptied, removed the container from the machine to empty and disinfect it and returned the container to the machine without re-cleaning the machine. On 6/18/25 at 9:35 AM, the surveyor observed a staff member cleaning and disinfecting the vacated dialysis station #9. The staff member failed to clean the laminated documents hanging from the IV pole and the counter behind the dialysis machine. A review of the facility’s policy titled, “Cleaning and Disinfecting the Dialysis Station,” published 09/05/2023 states in part: General Cleaning: The dialysis station could become contaminated with blood and other body fluids during treatment. After use, all non-disposable equipment and supplies must be disinfected with 1:100 bleach or manufacturer’s recommendations or discarded. ...Cleaning of the Dialysis Machine: Externally disinfect the dialysis machine with 1:100 bleach solutions after each dialysis treatment. ...Work Surface Cleaning and Disinfection w/out Visible Blood using Bleach Solutions: All work surfaces shall be cleaned and disinfected with 1:100 bleach solution after completion of procedures. Make the surface glisteningly wet and let air dry unless otherwise specified by the manufacturer. A review of the facility’s policy titled, “Cleaning and Disinfection the Dialysis Station Procedure,” states in part: ...3. Use a cloth wetted with 1:100 bleach solution of EPA-approved disinfectant to clean and disinfect the dialysis station (chair/bed, tables, machine, television, IV pole, B/P cuff, hand sanitizer dispenser and holder, etc.) Place the chair in Trandelenburg position and open side panels if chair has swing open sides so all surfaces of the chair are accessible. 4. Clean all surfaces. Make the surfaces glisteningly wet and allow to air dry unless otherwise specified by the manufacturer. The above findings were shared with Staff #1 prior to exit.”

“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: 33906 Based on observation, interview and document review, it was determined the facility staff failed to follow the facility’s guidelines for central venous catheter (CVC) care for one (1) of two (2) exit site care observations. The findings included: On 06/18/25 at 9:35 AM, the surveyor observed Staff #8 providing care to Patient #8. Patient #8 has a central venous catheter which is used for dialysis access. The supplies needed to initiate dialysis are bundled together prior to the patient’s arrival. Staff #20 placed a clean field under the catheter limbs, removed the old catheter site dressing, and disposed of the dressing. After hand hygiene and clean gloves, Staff #8 cleaned the area around the catheter allowed the site to dry and then taking a piece of gauze from the supplies, covered the site with gauze and applied a transparent waterproof dressing. After observing the care provided by Staff #8, the surveyor spoke to the Charge Nurse (Staff #10) and reviewed the supplies that are bundled together for use when accessing a CVC and providing exit site care. Staff #10 confirmed the gauze in the bundle was clean gauze that is used when a “tegaderm” dressing is used instead of the “island” dressing. The “island” dressing is sterile. Review of facility procedure “Changing the Catheter Dressing Procedure” published 05/02/2025 procedure found the following in part under supplies needed: “Catheter dressing (Gauze type dressings: Sterile gauze, Island or Transparent dressing as indicated on FKC products formulary). The above findings were shared with Staff #1 prior to exit.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 33906 Based on observations and interviews, it was determined the facility staff failed to ensure patients’ skin over their access sites were washed with soap and water or an antibacterial scrub before proceeding with skin antisepsis for two of two observations. The findings include: The facility staff failed to ensure Patient #6 and Patient #7’s access site was cleaned with soap and water or an antibacterial scrub prior to proceeding with skin asepsis. The surveyor conducted observations of Staff #8 (a Hemodialysis technician) initiating the hemodialysis treatment for Patient #7 on 06/18/25 at 9:30 AM. The surveyor observed the patient enter the treatment floor, weigh and then proceed to the dialysis chair. Patient #7 was in the chair at the dialysis station waiting for Staff #8 to began to initiate the treatment. Staff #8 did not ask the patient about whether he/she had cleaned his/her access site with soap and water. Staff #8 did not wash the access site with soap and water or an antibacterial scrub. Staff #8 evaluated the access site and proceeded to apply the antiseptic and initiate treatment. The surveyor conducted observations of Staff #13(a hemodailysis technician) initiating the hemodialysis treatment for Patient #6 on 06/18/25 at 9:55 AM. The surveyor observed the patient enter the treatment floor, weigh and then proceed to the dialysis chair. Patient #6 was in the chair at the dialysis station waiting for Staff #13 to began to initiate the treatment. Staff #13 did not ask the patient about whether he/she had cleaned his/her access site with soap and water. Staff #13 did not wash the access site with soap and water or an antibacterial scrub. Staff #13 evaluated the access site and proceeded to apply the antiseptic and initiate treatment. The surveyor reviewed the facility’s procedure for “Access Assessment and Cannulation” on 05/05/25. The procedure included, in part, the following: “Prior to treatment, ask your patient to wash access area with liquid soap for one minute, rinsing well. Dry with clean paper towel. Wash access (per above) if patients unable to clean their access.” “70% isopropyl alcohol pad: Using gentle friction, clean the access site...and allow to dry before cannulating.” The above findings were shared with Staff #1 prior to exit.”