Gundersen Lutheran Renal Dialysis - Onalaska

“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: 34337 Based on observation, record review and interview, facility staff failed to perform hand hygiene after touching the dialysis machine during catheter care in 1 of 2 patients observed (Patient #2), in a total sample of 10 patient observations. Findings include: Review of facility policy “Infection Control: Renal Dialysis, RD-4950” dated 11/21/2025 revealed “5. A. Good hand washing technique will be used prior to patient care, after removing gloves when a procedure is complete, between patients, machine contact...” During observation on 3/19/2025 at 9:20 AM, Registered Nurse H, while in the process of disconnecting Patient #2’s central venous catheter after treatment, touched the machine to silence an alarm then resumed catheter disconnection and disinfection without changing gloves and performing hand hygiene. During an interview on 3/19/2025 at 4:30 PM, Care Manager C stated staff are “told not to” touch the machine without performing glove change and hand hygiene.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 34337 Based on observation, record review and interview, facility staff failed to remove lab coat when exiting the treatment area and entering the water room for 1 of 2 staff observed (Certified Hemodialysis Technician I) in the water room. Findings include: Review of facility policy “Infection Control: Renal Dialysis, RD-4950” dated 11/21/2025 revealed “b. PPE [personal protective equipment] (including lab coats) should be removed before leaving the dialysis area...” Per observation on 3/18/2025 at 8:50 AM, Certified Hemodialysis Technician I exited the treatment area and entered the water room without removing their lab coat. During an interview on 3/19/2025 at 4:30 PM, Care Manager C stated PPE is “supposed to come off” when exiting the dialysis treatment area, and “we have hooks” to place coats at the treatment floor exits.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 34337 Based on observation, record review and interview, facility staff failed to dispose biohazard waste appropriately in 1 of 10 patient observations (Patient #4), in a total of 10 patient observations. Findings include: Review of facility policy “Infection Control: Renal Dialysis, RD-4950” dated 11/21/2025 revealed “G. Blood-contaminated trash items that are dippable or pourable will be placed in appropriate biohazard waste receptacles.” During an observation of Patient #4’s initiation of treatment on 3/18/2025 at 10:40 AM, Registered Nurse F disposed 2 blood-filled syringes into the chairside garbage can. During an interview on 3/18/2025 at 12:10 PM, Nurse Manager J stated blood-filled syringes should be disposed of in either the sharps or biohazard container and not in the regular garbage.”

“POC-VA MONITOR/PREVENT FAILURE/STENOSIS CFR(s): 494.90(a)(5) The patient’s vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis. This Standard is not met as evidenced by: 34337 Based on observation, record review and interview, facility staff failed to assess for bruit and thrill when using clamps to achieve hemostasis after treatment for 1 of 2 patients observed (Patient #1) using clamps, in a total sample of 10 patients observed. Findings include: Review of facility policy “Access Cannulation and De-Cannulation of Arteriovenous Fistula (AVF) and Arteriovenous Graft (AVG), RD -6200” dated 10/30/2024 revealed “Post Dialysis Needle Site Care: ... 4. c. Staff will listen for a bruit or feel for a thrill after applying clamps to vascular access site. ...6. Achieve hemostasis. 7. RN to assess bruit and thrill before discharging patient.” Per observation on 3/18/2025 at 11:00 AM, Registered Nurse D removed needles from Patient #1’s AVF after treatment and applied clamps to each the venous and arterial needle access sites. The clamps were secured in place with tape. After hemostasis was achieved, at 11:25 AM, Registered Nurse E removed the clamps and secured the needle sites. Neither Registered Nurse D nor Registered Nurse E were observed assessing Patient #1’s AVF site for bruit or thrill prior to discharge. Per medical record review, Patient #1’s treatment ended at 11:00 AM. Arterial/Venous bleed time was documented at 11:10 AM as “Clamp used; 15 minutes.” AVF assessment was documented at 11:10 AM, not after achieving hemostasis and prior to discharge. During an interview on 3/18/2025 at 2:15 PM, Registered Nurse E stated using clamps to achieve hemostasis after dialysis is “not ideal” and there are “risks... [clamps] can cause damage to fistulas.” During an interview on 3/19/2025 at 2:05 PM, Medical Director G stated assessment of bruit/thrill after using clamps “should be done.””

“QAPI-INDICATOR-INF CONT-TREND/PLAN/ACT CFR(s): 494.110(a)(2)(ix) The program must include, but not be limited to, the following: (ix) Infection control; with respect to this component the facility must- (A) Analyze and document the incidence of infection to identify trends and establish baseline information on infection incidence; (B) Develop recommendations and action plans to minimize infection transmission, promote immunization; and (C) Take actions to reduce future incidents. This Standard is not met as evidenced by: 34337 Based on record review and interview, facility staff failed to track and trend facility vaccinations to monitor ongoing performance for 3 of 3 vaccination rates reviewed (influenza, hepatitis B, pneumonia); and failed to implement preventive actions for 1 of 1 patient infections reviewed (Patient #3). Findings include: Review of the facilty’s vaccination data dated August 2024 revealed facility immunizations are not meeting goal for influenza and hepatitis. There was no tracking of data over time to establish trends. During an interview on 3/19/2025 at 3:45 PM, Administrator B stated there was not an action plan in place for the facility’s vaccination rates and was unable to state how the facility determines if vaccinations rates are a problem without tracking and trending of data. Review of facility quality data revealed patient infections were identified as a problem area with a developed action plan. Review of Patient #3’s infection event revealed Patient #3 had a central venous catheter blood stream infection on 11/10/2024 which resulted in a hospitalization with subsequent removal and insertion of a new central venous catheter. The facility’s preventative measures were documented as “patient education, staff education.” There was no documentation of potential contributing factors. Review of Patient #3’s medical record did not include any documentation of infection prevention or catheter-related education after the infection event. During an interview on 3/19/2025 at 3:50 PM, Unit Leader A stated infection events are discussed at quality meetings. When asked about implementation of the preventive measures as documented, A stated all patients receive catheter infection prevention education annually in August, but there was no additional education provided to Patient #3 after their hospitalizaton for catheter infection.”