University of Vermont Medical Center Dialysis Newport

“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: 43524 Based on observation and staff interview, staff failed to wear and change disposable gloves and perform hand hygiene during the provision of patient care and care of dialysis (a treatment that removes waste products and excess fluid from the blood when the kidneys are no longer functioning properly) equipment for 2 applicable patients. (Patients #12 & #13) Findings include: 1. Per observation on 10/21/24 at 11:30 AM, prior to cannulation (a procedure that involves inserting a cannula, or catheter, into a vein or artery) of Patient #12’s AV fistula (an abnormal connection between an artery and a vein), the Patient Care Technician (PCT) failed to cleanse hands and change gloves after contaminating the gloves worn by touching the safety glasses worn upon the top of their head and placing them upon their face in preparation for initiation of dialysis. They then inserted the first needle and again touched the safety glasses on their face and moved them to the top of their head, again failing to cleanse hands and change gloves. Then they took the second line from the machine with their right hand and took their safety glasses from the top of their head and placed them on their face with their left hand and proceeded to insert needle #2. They then took the safety glasses from their face and moved them up to the top of their head. They then secured the lines to the patient with tape, added information into the chair side stand up computer, added a gauze pad to the patient’s needle insertion sites and then removed their gloves. They then put on new gloves without hand sanitizing, re-adjusted the patient’s blood pressure cuff, took off their gloves and hand sanitized. 2. Per observation on 10/21/24 at 12:05 PM the PCT removed their gloves, exited station #5, put new gloves on without hand santizing and went to station #2 to assist other staff with patient #13. Per interview at 12:15 PM, the PCT confirmed that gloves should have been changed and hands cleansed after touching their safety glasses prior to accessing Patient #12’s fistula and every time gloves are donned (putting on) or doffed (taking off). They also confirmed that they should have hand sanitized prior to donning gloves when proceeding to station #2 to assist with patient care. They stated, “I always try to hand sanitize before putting on gloves and after taking them off.” Per interview on 10/21/24 at 1:00 PM with the facility’s medical director confirmed that hand sanitizing is required when before donning gloves and after doffing gloves. Per interview on 10/21/24 at 1:15 with the Manager RN RNS (Renal Nurse Supervisor) confirmed that it is a requirement that hand sanitizing is done every time gloves are donned or doffed gloves and safety glasses are required “during site access and when there is any chance of blood spray.” They stated that gloves must be changed when going from clean to dirty and dirty to clean. They stated that touching anything dirty like touching hair, personal clothing, safety glasses, any glasses, computer, are considered dirty and require gloves changes and hand sanitizing.”

“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: 29776 Based upon observation and interview, the facility failed to ensure appropriate infection control measures were followed to prevent intravascular catheter (a flexible, long, plastic, y-shaped tube that is threaded through your skin into a central vein in your neck, chest or groin)* -related infections for 1 patient [Pt.#4] of 3 patients sampled. Findings include: Per observation on 10/21/24 at 12:45 PM, a staff Registered Nurse [RN] was observed during dialysis initiation for Pt.#4. While the RN was accessing Pt.#4’s Central Venous Catheter [CVC] on the patient’s left upper chest wall in preparation for dialysis treatment, the patient was observed without a mask. Per interview with the facility’s Renal Nurse Supervisor [RNS] on 10/21/24 at 3:50 PM, the RNS confirmed that staff should ensure that dialysis patients with Central Venous Catheters [CVCs] are wearing masks during accessing and de-accessing their CVC in order to prevent intravascular catheter-related infections. The RNS confirmed that staff are educated annually on CVC accessing and de-accessing, and the expectation was the patient is to be masked during accessing and de-accessing the CVC. The RNS confirmed the observation was not in accordance with the facility’s CVC policy and procedure. An interview was conducted with the facility’s Medical Director on 10/22/2024 at 1:00 PM. The Medical Director stated that ‘it doesn’t matter’ whether accessing a patient’s Central Venous Catheter [CVC] during initiation of dialysis or de-accessing the CVC after dialysis is completed, the patient must be wearing a mask for infection control precautions, and staff are to ensure this is done. *(https://www.azuravascularcare.com/infodialysisaccess/types-of-dialysis-access/)”