Davita Mountaineer Dialysis

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 38282 Based on observation and staff interview, it was determined the facility failed to provide, monitor, and maintain a sanitary environment to minimize the transmission of infectious agents to patient access sites on the in-center treatment floor. This failure was observed in five (5) out of seventeen (17) treatment stations (stations #9, #10, #11, #12, and #15); and has the potential to adversely affect all patients receiving treatment at the facility. An observation was conducted on 02/26/24, starting at 10:40 a.m. of the inpatient dialysis treatment area, accompanied by Employee #1. Paper and plastic trash was noted to be on the floor at station #10, #11, and #12. Gloves were noted to be on the floor, as well as trash, at station #15. Several trash cans were overflowing with trash. A large liquid spill was noted to be on the floor by the sink at the medication desk that was cleaned up by Employee #1 after it was questioned. At station #9, there was a large area of a white powdery substance on the floor between the dialysis machine and patient chair, with a patient present and receiving dialysis. An interview was conducted on 02/26/24, at 11:00 a.m. with Employee #1 regarding the condition of the inpatient treatment floor. Employee #1 stated: “The second shift starts around 10:30 a.m. and it can be hectic. Staff need to be more aware of the trash accumulation and water spills in their environment.” Employee #1 explained that the white powdery substance on the floor was most likely bicarbonate that settled out from a dialysate spill; and concurred that it would have had to be on the floor several hours without wiping it up to leave that deposit. Employee #1 then concurred that the state of the inpatient treatment area was not conducive to a sanitary environment.”

“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: 38282 Based on observation, document review and staff interview, it was determined the facility failed to ensure that blood pressure cuffs remained off the floor during patient use; and that blood spills were cleaned in the glucose monitoring area. This failure has the potential to adversely affect all patients receiving dialysis at the inpatient treatment center. An observation was conducted on 02/26/24, starting at 10:40 a.m. of the inpatient treatment center area, accompanied by Employee #1. At station #12, a reusable blood pressure cuff was noted to be attached to the dialysis machine and lying on the floor, along with paper and plastic trash, with a patient present and receiving dialysis at that station. A side hallway leading to the water treatment room had a counter where the staff used a glucometer to check patient glucose levels. There was a small absorbent pad with the glucometer lying on it. The pad had several blood stains and two (2) used glucose strips. Employee #1 removed the pad and glucose strips and disposed of them when questioned. When the pad was removed, a dried blood smear was noted to be on the counter under the pad. Another staff member placed a clean pad onto the counter and laid the glucometer on the fresh pad, without cleaning the counter or the glucometer. An observation was conducted on 02/27/24, at 10:35 a.m. of the glucometer area where staff use a glucometer to check patient glucose levels. The absorbent pad had the glucometer on it, and there was a quarter-sized blood stain on the pad. A review of the policy, titled “Infection Control for Dialysis Facilities” revised 04/2023 stated, in part, “Disinfection: Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials ... “Cleaning of visible blood should be performed when first observed ... “Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between uses ...” An interview was conducted on 02/28/24, at 9:30 a.m. with Employee #1 regarding the blood pressure cuff and the glucometer area. Employee #1 concurred that the blood pressure cuff should not have laid in the floor adjacent to trash; and that it should have been retrieved and cleaned, and the trash picked up, as the patient was still receiving treatment. Employee #1 explained that diabetic patients, and other patients with physician orders, had their glucose checked prior to a treatment. And stated: “The staff obtains blood in a syringe when accessing the patients’ fistula or central venous access (CVC). They bring the syringe to the glucometer area and use it on the glucometer, and sometimes it squirts and leaves a mess.” Employee #1 then concurred that all blood spills should be cleaned and disinfected immediately, and that the blood-stained absorbent pad and used glucometer strips should have been discarded.”