Mayo Clinic Dialysis - London Road

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 27438 Based on observation, interview, review of policy, the facility failed to ensure that the handheld instant read thermometers were cleaned appropriately after use. This deficient practice had the potential to cause bacteria to grow with the potential to cause harm by infecting the 72 patients receiving in-center hemodialysis at the facility. Findings included: During an observation on 03/19/24 at 11:35 AM, at Station 21 Certified Hemodialysis Technician (CHT)7 failed to disinfect the thermometer after use then returning it to the designated clean counter. During an observation on 03/19/24 at 12:10 PM, at Station 20 CHT 7 failed to disinfect the thermometer after use then returning it to the designated clean counter. During an interview on 03/19/24 at 12:30 PM, CHT 7 confirmed he/she failed to disinfect the thermometer prior to returning the thermometer to a designated clean counter area. CHT 7 stated the facility policy was to disinfect the thermometer after each use. During an interview on 03/20/24 at 11:30 AM, the Nurse Manager confirmed the facility policy for disinfection of the thermometers after use and prior to placing on the designated clean counter. Review of the facility’s policy titled, “Infection Prevention and Control Procedure,” revision date 12/18/23, indicated, “Perform cleaning and disinfection of environmental surfaces with institutionally approved disinfectant between patient uses and after the patient has left the station. Surfaces include but are not limited to...thermometers.””

“ENVIRONMENT-SECURE & RESTRICTED CFR(s): 494.40(a) 8 Environment: secure & restricted The water purification and storage system should be located in a secure area that is readily accessible to authorized users. The location should be chosen with a view to minimizing the length and complexity of the distribution system. Access to the purification system should be restricted to those individuals responsible for monitoring and maintenance of the system. This Standard is not met as evidenced by: 27438 Based on observation and interview, the facility failed to restrict access to the water purification room to only authorized users. Failure to restrict access to the water purification room to only authorized users who were responsible for monitoring and maintaining the water purification, had the potential to negatively impact the safety and well-being of the 72 in-center dialysis patients receiving treatments at this facility. Findings include: During the flash tour observation on 03/18/24 at 9:00 AM, the Nurse Manager used a four-digit keyless security code to unlock the door to enter the locked clean supply room. Upon completing a tour of the clean supply room, the Nurse Manager used the same four-digit keyless security code to enter the designated water purification system room. The Nurse Manager confirmed at that time that the same four-digit keyless security code opened both the clean supply room and the water purification system room door. During an interview on 03/18/24 at 2:30 PM, the Biomedical Technician confirmed not all facility staff are trained and/or authorized to operate facility water purification system and the security door to the water purification system should be programed differently. During an interview on 03/19/24 at 3:50 PM, the Medical Director confirmed he/she was not aware the security door to the water purification system should be programed differently. At the time of exit the facility was unable to provide a policy related to the security of the water purification room.”