Uva Page 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: 49355 Based on observations and document review, it was determined the facility failed to ensure that dialysis stations and chairs were appropriately disinfected between patients in three (3) out of three (3) observations. The findings include: On 07/22/2024 at 10:30 a.m., Staff Member #1 failed to disinfect the outside arms of the dialysis chair at station #3 underneath both side trays. At 10.55 a.m., Staff Members #1 and #3 were each cleaning a side of the dialysis chair at station #2. Neither staff member disinfected the outside arms of the dialysis chair underneath both side trays. These findings were discussed with Staff Members #5 and #10 at the end of the day on 07/22/2024. A review of the facility’s policy entitled, “Dialysis Specific Infection Prevention and Control Policy Number DP514,” with a last revision date of March 2022 reveals: ... “G. ENVIRONMENTAL CLEANING: ... a. After a patient completes their treatment...surfaces of all equipment must be thoroughly cleaned/disinfected as specified below. ... b. PDI Super Sani Wipes (purple top) are used for routine cleaning and disinfection of surfaces for patient stations....” The above concerns were discussed at the exit conference on 07/24/2024 at 9:35 a.m. with Staff Members #5, 6, 7, 9, 10, 11 and 13.”

“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: 49355 Based on observations, interviews, and document review, it was determined the facility staff failed to aseptically access an arteriovenous (AV) graft/fistula in two (2) out of three (3) observations. The findings include: At 11:00 a.m. on 07/22/2024, the surveyor observed Staff Member #2 accessing an AV fistula on Patient #3 at station #9. The Staff Member cleaned the area and then palpated the site. Staff Member #2 then accessed the site with the cannulation needle without cleaning the area again. At 11:13 a.m., Staff Member #4 disinfected the fistula site on Patient #5 are station #4. The Staff Member then palpated the site before accessing, without cleaning the area again. In discussions with Staff Members #5 and 10 on 07/22/2024 at the end of the day, there was agreement that these access areas should have been recleansed before inserting the needles. In a review of the facility’s policy entitled, “Initiation of Dialysis for Fistula or Graft - Braun Machine No. DP544,” approved on 03/2024, it was revealed: ... “D. SUPPORTIVE DATA: ... 2. Staff members need to maintain aseptic technique when cannulating the patient’s vascular access and the initiation of hemodialysis.” The above observations were discussed at the exit conference on 07/24/2024 at 9:35 a.m. with Staff Members #5, 6, 7, 9, 10, 11 and 13.”

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 40084 Based on observation, interview and document review, it was determined the facility’s Quality Assurance and Performance Improvement (QAPI) program failed to take action to ensure sustained improvement over time. Specifically, the QAPI program failed to correct known issues identified during the previous recertification survey. The findings include Tag V-0122 Current Recertification Survey Based on observations and document review, it was determined the facility failed to ensure that dialysis stations and chairs were appropriately disinfected between patients in three (3) out of three (3) observations. Recertification Survey Ending June 23, 2021 Based on two (2) infection control observations, interviews, and document review, it was determined that facility staff failed to properly clean and disinfect the dialysis station. Tag V-0550 Current Recertification Survey Based on observations, interviews, and document review, it was determined the facility staff failed to aseptically access an arteriovenous (AV) graft/fistula in two (2) out of three (3) observations. Recertification Survey Ending June 23, 2021 Based on one (1) infection control observation, interviews, and document review, it was determined facility staff failed to maintain asepsis prior to accessing arteriovenous (AV) fistula (an internal dialysis access surgically created by connecting an artery and a vein) for dialysis treatment.”