Davita Harrison County Dialysis

“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: 40269 Based on policy review, document review, observations and staff interview, it was determined the facility failed to utilize hand hygiene to prevent contaminant transmission in two (2) out of two (2) observations conducted for discontinuation of dialysis and post dialysis access care for AV (arteriovenous) fistula, of patient 6 and 7. This failure has the potential to negatively impact all dialysis patients at the facility. Findings include: A policy was reviewed titled “Infection Control for Dialysis Facilities”, last revised 04/23. The policy states in part, “...Policy: The Centers for Disease Control (CDC) Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients (Dialysis Precautions) will be followed when caring for all patients ...Hand Hygiene: 1. All teammates, Physicians and non Physicians (NPP) will perform hand hygiene...b. prior to gloving and immediately after removal of gloves...” A CDC document was reviewed titled, “Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients”, dated 04/27/01. The document states in part, “...Infection Control Precautions for Outpatient Hemodialysis Settings Compared with Inpatient Hospital Settings ...In the hemodialysis setting, contact transmission plays a major role in transmission of bloodborne pathogens. If a health-care worker’s hands become contaminated with virus-infected blood from one patient, the worker can transfer the virus to a second patient’s skin or blood line access port, and the virus can be inoculated into that patient when the skin or access port is punctured with a needle. Contact transmission can be prevented by hand hygiene (i.e., hand washing or use of a waterless hand rub), glove use, and disinfection of environmental surfaces. Of these, hand hygiene is the most important. In addition, nonsterile disposable gloves provide a protective barrier for workers’ hands, preventing them from becoming soiled or contaminated, and reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to patients. However, even with glove use, hand washing is needed because pathogens deposited on the outer surface of gloves can be detected on hands after glove removal, possibly because of holes or defects in the gloves, leakage at the wrist, or contamination of hands during glove removal...” A CDC document was reviewed titled, “Clinical Safety: Hand Hygiene for Healthcare Workers”, dated 02/27/24. The document states in part, “...Recommendations: Know when to clean your hands: Immediately before touching a patient. Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices. Before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or patient’s surroundings. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal...” An observation was conducted at the facility on 12/01/25 at 11:38 a.m. of staff 2 conducting “Discontinuation of Dialysis and Post Dialysis Access Care for AV Fistula or Graft” with patient 6. During the observation, after staff 2 disconnected the patient’s bloodlines, staff 2 removed their gloves, then donned new gloves without performing hand hygiene. An observation was conducted at the facility on 12/01/25 at 12:36 p.m. of staff 3 conducting “Discontinuation of Dialysis and Post Dialysis Access Care for AV Fistula or Graft” with patient 7. During the observation, after staff 3 disconnected the patient’s bloodlines, staff 3 removed their gloves, then donned new gloves without performing hand hygiene. An interview was conducted with staff 1 on 12/02/25 at 11:45 a.m. When discussing the above findings, staff 1 explained, “The policy says you must perform hand hygiene when changing gloves. The staff should have performed hand hygiene before donning a new set of gloves.””