QA Investigation Results

Pennsylvania Department of Health
BUTLER COUNTY DIALYSIS CENTER
Health Inspection Results
BUTLER COUNTY DIALYSIS CENTER
Health Inspection Results For:


There are  9 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on May 11, 2018, Butler County Dialysis Center was found to be in compliance with the requirements of 42 CFR, Part 494.62, Subpart B, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services - Emergency Preparedness.



Plan of Correction:




Initial Comments:


Based on the findings of an onsite unannounced Medicare recertification survey completed May 11, 2018, Butler County Dialysis Center was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the following requirements of 42 CFR, Part 494, Subparts A, B, C, and D, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services.







Plan of Correction:




494.30(a)(1) STANDARD
IC-WEAR GLOVES/HAND HYGIENE

Name - Component - 00
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.




Observations:

Based on review of facility policy and procedure, observation (OBS), and staff (EMP) interview, the facility failed to ensure one (1) of two (2) patients observed holding their access performed hand hygiene after glove removal and before touching equipment (OBS#5.2).

Findings included:

Review of facilty policy and procedure on May 10, 2018, at 9:15 a.m. showed, "INFECTION CONTROL/BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN ... C. Work Area Restriction ... 14. Patients who hold their own sites must wear gloves. When sites are occluded, gloves are removed, and patients [are] instructed to wash their hands before touching equipment and leaving the treatment area."

Review of facility's "Infection Control Audit" form on May 10, 2018, at 9:15 a.m. showed, "Discontinuation with AVF ... V113 Remove gloves, hand hygiene (patient or visitor who held sites, remove gloves, hand hygiene) before touching any equipment such as the scale."

Observation (OBS#5.2) of discontinuation of dialysis with an arteriovenous fistula (AVF) on May 8, 2018, at 10:10 a.m. revealed EMP7 remove needles from patient's AVF. EMP7 covered the needle sites with gauze bandages and tape, and the patient held pressure to the top needle site bandage with a gloved left hand. After bleeding had stopped the patient removed glove from left hand, but did not perform hand hygiene. The patient then walked to the scale and pushed buttons on the scale's control panel with both hands. Interview with EMP7 after observation confirmed findings.









Plan of Correction:

V 0113

An in-service was given to all Direct Patient Care (DPC) staff by 5-30-18 by the Clinic Manager (CM) regarding preventing cross contamination. During the in-service emphasis was placed on patients who hold their own sites, must wash their hands immediately after their gloves are removed and before touching any surfaces such as the scale or door and before leaving the treatment area. Per Policy:
"Patients who hold their own sites must wear gloves. When sites are occluded, gloves are to be removed, and patients instructed to wash their hands before touching equipment and leaving the treatment area."
A letter will be given to all patients by the Medical Director instructing patients who hold their own sites that they must wash their hands before touching any equipment, such as the scale and when leaving the treatment area by 5-30-18. The staff member providing care for the patient must ensure that the patient washes his/her hands when gloves are removed after holding sites prior to touching other objects and before leaving the treatment area. If the patient touches objects, such as the scale or door, prior to hand washing, the surface touched must be immediately cleaned with a 1:100 bleach solution by a staff member and the patient immediately educated on the importance of performing hand washing immediately after glove removal. This education should be documented in the medical record. The Infection Control (IC) Audit was updated to include cleaning of the surfaces if the patient fails to wash their hands after glove removal and patient education regarding hand washing after glove removal. The IC audit, normally completed monthly, will now be completed weekly for 8 weeks by an assigned DPC staff member. The Clinic Manager will also complete one audit per week for 8 weeks. The first weekly Infection Control audit was conducted by a DPC staff member on 5/25/18 and by the clinic manager on 5/22/18 and will continue weekly until 100% compliance is achieved for 3 consecutive audits (minimum of 8 weeks).The Clinic Manager will ensure compliance through direct observation and through review of the Infection Control Audits. All findings will be addressed at the monthly Total Quality Management (TQM) Meeting and additional action will be taken as deemed appropriate by the committee, such as more education, continuing the weekly audits or if trends are identified, disciplinary action.



IN-SERVICE RECORD LISTED BELOW:



American Renal Associates
Butler County Dialysis Center
In-service Attendance Record

Date Initiated:

In-service: Patient hand washing after glove removal (V0113)

Instructor: Title:

Critique of Material Covered:

- Patients, who hold their own sites, must wash their hands immediately after their gloves are removed and before touching any surfaces such as the scale or door and before leaving the treatment area.
- Per Policy: "Patients who hold their own sites must wear gloves. When sites are occluded, gloves are to be removed, and patients instructed to wash their hands before touching equipment and leaving the treatment area."
- The staff member providing care for the patient must ensure that the patient washes his/her hands when gloves are removed after holding sites prior to touching other objects and before leaving the treatment area.
- If the patient touches objects, such as the scale or door, prior to hand washing, the surface touched must be immediately cleaned with a 1:100 bleach solution by a staff member and the patient immediately educated on the importance of performing hand washing immediately after glove removal. This education should be documented in the medical record.
- Review of the letter to be distributed to all patients
- Review of the updated Infection Control Audit and increased frequency in monitoring.
Date Print Name Signature Title



PATIENT LETTER LISTED BELOW:



May 16, 2018


Dear Patient:

I am sending this letter to inform you of a practice that was brought to my attention as of a recent survey at the facility. The quality of care that we deliver to you is of utmost importance and I am asking you to help us in maintaining the best and safest care for you, our patients.

- To help prevent the potential for infection, you must wash your access site with antimicrobial soap upon entering the dialysis treatment area, prior to sitting in the dialysis chair. It is not acceptable to use sanitizing hand wipes (Sani-Hands) or an alcohol based hand sanitizer (such as Purell) in place of soap and water. If you need assistance in washing your access, please notify a staff member who will assist you.

- If you hold your own access sites at the end of your treatment, you must wear gloves and when your access has stopped bleeding and your gloves are removed, you must sanitize or wash your hands before you touch any equipment (such as the scale) and/or leave the treatment area. If your hands are visibly soiled after removing gloves, wash your hands for 15 seconds with anti-microbial soap and water, followed by thorough rinsing and use of disposable paper towels for drying. Alcohol based hand sanitizers are recommended by the CDC, if hands are not visibly soiled.

I appreciate your acceptance of these responsibilities and we will continue to strive to make this facility the best in the area.

Thank you,



Clinic Manager



INFECTION CONTROL AUDIT LISTED BELOW:



American Renal Associates
Infection Control Audit Clinic Name: Butler County Dialysis Center
To be performed at least monthly (all direct patient care staff) as a peer review or by management staff. If problems are noted, the frequency of doing this audit should be increased. Non-compliance to be addressed with staff members and audit to be brought to the monthly TQM meetings.


Date: ______________________________ Employee Signature

Station Number Comments
Staff Member
VTAG Treatment Floor Flash Tour
V122 Blood spills immediately cleaned with a 1:100 BLEACH SOL'N X2 (1:10 in OH and MI); no visible wet or dry blood (cleaned twice)
V120 HD machine transducer protectors clean and dry. If wet with blood, procedure followed.
V404 Sufficient space to prevent cross-contamination and use emergency equipment
Initiation with CVC
V116 No common tray/cart brought to dialysis station (supplies for only that patient brought to station)
V113 Gown, Mask for patient and staff covers nose and mouth, Hand hygiene, Dons clean gloves
V147 Place clean field under CVC ports
V147 "Close the catheter clamps; Disinfect CVC hubs, using an appropriate antiseptic. May perform either (or both): --External disinfection by wiping exterior caps before removing; or
--Open hub disinfection by wiping the threads and top of uncapped hub with antiseptic, removing any residue/blood
--Closed connector devices which have penetrable caps not removed, wipe outside connecting surfaces of device
"
V147 Connect sterile syringes aseptically to each port to remove indwelling solutions and/or flush with sterile saline; qualified personnel to administer heparin if ordered; wait 5 mins for heparin dwell; initiate treatment (ensure prime is dumped per procedure)
V113 Remove gloves, hand hygiene
CVC Exit Site Care
V113 Gown, Mask for patient and staff covers nose and mouth, Hand hygiene, Dons clean gloves
V147 Remove old dressing and discard without contaminating clean supplies
V147 Remove gloves, hand hygiene, don clean gloves
V147 Cleanse area around CVC exit site with antiseptic; allow to dry before applying dressing
V147 Sterile dressing applied to CVC exit site; may apply antimicrobial ointment if not contraindicated or chlorhexidine- impregnated dressing if no sensitivity
V113 Remove gloves, hand hygiene
Discontinuation of Dialysis with CVC
V113 Gown, Mask for patient and staff covers nose and mouth, Hand hygiene, Dons clean gloves
V147 Place clean field under CVC ports
Reinfuse extracorporeal circuit
V113 Remove gloves, hand hygiene, don clean gloves
V147 Close CVC clamps; Disinfect CVC connections with appropriate antiseptic. May perform one or both: --External disinfection wiping exterior of connections b/4 disconnecting blood lines; or --Open hub disinfection wiping threads and top of open CVC hubs, removing any residue/blood after disconnecting blood lines --Closed connector devices: wiping exterior of connections before disconnecting blood lines
V147 Disconnect blood lines aseptically
V147 Apply sterile port caps aseptically after post treatment protocol (applicable to closed connector devices when changed)
V116 Discard unused supplies or dedicate to that patient; no disposable supplies returned to common supplies
V113 Remove gloves, hand hygiene
Initiation with AVF/AVG
V116 No common tray/cart brought to dialysis station (supplies for only that patient brought to station)
V550 Wash skin over access with soap and water or antibacterial scrub (patient or staff may do this); for dependent patients, staff must do this before proceeding with skin antisepsis
Pro 2-80 Wash hands, don PPE
Pro 2-80 Evaluate access; Locate/palpate cannulation sites
V113 Hand hygiene; don clean gloves
V550 Apply antiseptic to skin over cannulation sites and allow to dry; sites not touched again after skin antisepsis, without repeating skin antisepsis
Pro 3-20 Insert cannulation needles; tape in place (Pro 3-40); qualified personnel to administer heparin if ordered; wait 5 mins for heparin dwell; initiate treatment (ensure prime is dumped per Procedure)
V113 Remove gloves, hand hygiene
Discontinuation with AVF / AVG
V116 No common tray/cart brought to dialysis station (supplies for only that patient brought to station)
V113 Hand hygiene, don clean gloves
Reinfuse extracorporeal circuit; disconnect bloodlines aseptically
V113 Remove gloves, hand hygiene, don clean gloves
V550 V113 Remove needles aseptically with proper engagement of safety device; needles in Sharps container not on chair table; Needle sites held with clean gauze or bandage using clean gloved hands (patient, staff or visitor) or disinfected clamps; needles disposed of at point of use
V113 Remove gloves, hand hygiene
V550 When hemostasis is achieved: Hand hygiene, don clean gloves; replace blood- soiled bandage/ gauze on needle sites;
V550 V113 Bandage/gauze on each needle site is clean & dry prior to discharge
V116 Discard unused supplies; disinfect fistula clamps and hemostats
V113 Remove gloves, hand hygiene (patient or visitor who held sites, remove gloves, hand hygiene) before touching any equipment such as the scale.
Gloves are discarded in red biohazard receptacles and not in regular trash
Cleaning and Disinfection of Dialysis Station
V122 Remove all bloodlines and disposable equipment; discard in biohazardous waste with dialyzer and bloodlines transported in a manner to prevent contamination of other surfaces
V122 Empty and disinfect prime waste receptacle if present on machine
V113 Remove gloves, hand hygiene, don clean gloves
V122 Use disinfectant-soaked cloth/wipe to visibly wet all machine top, front and side surfaces, dialysate hoses, Hansen connectors, IV Poles and outside surfaces of dialysate concentrate containers
V122 Wipe wet all internal and external surfaces of prime waste container and allow to dry
V116 V122 When chair is vacated: discard unused disposable supplies; wipe chair in Trendelenburg, and arm rests, sides of chair open if applicable fresh 1:100 bleach cloth used to visibly wet all external chair surfaces
V122 Bleach cloths are not kept on machine or chair
V122 Non-disposable items: BP cuff & tubing, TV & side arm, call button, data entry station and counters around dialysis station wiped wet with 1:100 bleach cloth
V116 Clamps cleaned of visible blood and disinfected before placing in 1:100 bleach solution for 10 minutes and then air dried before use
V113 Discard cloths/wipes; remove gloves, hand hygiene
If individual trash can used in the station, trash is emptied between patients and disinfected
General
V122 Mixing instructions for 1:100 bleach are posted
V119 Supplies are kept in designated clean areas, sufficient distance from stations to prevent contamination
V119 Supplies for next patient are not brought to the station before applicable piece of equipment (machine, chair) is cleaned/disinfected
V119 Staff do not keep pens or supplies on their person
V116 Non-disposable equipment (thermometer, pH/conductivity meter, O2 concentrator, blood glucose meter, stethoscope) brought to the dialysis station is disinfected before being returned to a clean area
V116 Disposable supplies taken to the dialysis station not used are discarded
V113 Clean glove donned completely when working with patient or machine
V115 Appropriate PPE worn and gown completely buttoned
V115 PPE removed when leaving treatment area
V113 Staff wash hands prior to entering and exiting treatment area
V114 Clean, Handwashing, and Dirty sinks used and labeled appropriately
V121 Infectious waste in Red Bags only
V122 1:100 (1:10 in OH and MI) bleach used to clean area; visible blood cleaned a 2nd time with new cloth
Treatment sheet clipboards (folder used, kept clean per facility procedure, HIPPA maintained)
B/P cuff sleeves are protecting B/P cuff on both sides
V121 Wastes/sharps are properly secured handled & disposed of properly and are not greater than full.
V120 Transducers changed when wet and between treatments. If blood on the reverse side of the transducer filter, machine is tagged and the internal transducer is checked by technical before next use.
V142 Patients with MRSA, VRE, VRSA (have own supplies)
V115 No eating, drinking or gum chewing in treatment area
V122 1:100 bleach solution made fresh daily
V122 Station vacated prior to cleaning / set up.
V228 Bi-Carts, Bi-Bags, Bicarb jugs dated (if used)
Isolation Room
V128 HBV+ patient isolated in a room or with a space of 1 station between
V131 Staff caring for HBV+ patients are HBV immune
V131 Staff not delivering care to HBV+ and HBV susceptible patients on the same shift
V130 Isolation equipment and supplies dedicated for use on HBV+ patients only and labeled "isolation" (V130)
V128 No non HBV+ patients dialyzing in the isolation room when an HBV+ patients is on the census
V130 All PPE worn on tx floor removed and hand hygiene prior to entering isolation room
V130 Appropriate PPE used when in isolation room
V130 All isolation PPE removed including facemask and hand hygiene prior to leaving room
V128 Door closed (if present) during times of potential splash or splatter
Lab tubes double bagged in biohazardous bags
Isolation waste double bagged in Red Bags
Tri Station
V403 Tubing clean and free of growth
V403 Bleach 1:100 changed daily
V403 RO water changed daily
Parenteral Medication Prep and Administration
V113 Hand hygiene
V143 Wipe stopper with alcohol or other antiseptic after removing septum cap and prior to each entry into a multi-dose vial (new pad each time)
V117 Withdraw medication into sterile syringe; Label syringe if medication not immediately administered
V117 Prepped in designated Clean area, delivered to each patient separately. Gloves removed, hands sanitized & new gloves donned before each injection.
V113 V115 Hand hygiene, don clean gloves and other PPE as indicated by potential exposure (e.g., gown and mouth/nose/eye protection if injecting into blood lines)
V143 Wipe injection port with antiseptic; inject medication (V143)
V121 Discard syringe into Sharps container (Exception: If using a needleless system with no attached needle)
V113 Remove gloves, hand hygiene
V118 Single dose vials used for one patient only and discarded
V143 Multiple dose vials are only entered with a new, sterile syringe and needle discarded within 28 days or by manufacturer's instructions (FL all only 28 days)
V117 Prepared in a clean area away from dialysis stations
V143 Proper aseptic technique used
Facility Specific
POC Patients who hold their own access wash their hands immediately after glove removal. If not and objects (scale, door) are touched, the object is cleaned with a 1:100 bleach solution, the patient educated and the education documented.
POC Dialysate solutions used to check the conductivity of the machine is only discarded in the dirty sink.
POC Hand Washing Sinks are for hand washing only.
POC All items (clipboards, pens, Phoenix meter, etc.) cleaned with a 1:100 bleach solution prior to being placed on a clean surface or in a clean area or prior to being taken into another treatment station.
POC Patints wash their vascular access with antimicrobial soap and water prior to access cannulation (hand sipes and alcohol hand sanitizers CANNOT replace soap and water).
POC Staff visualizes all cannulation sites to ensure that hemostasis has occurred and new clean gauze is applied after hemostasis.

To be completed monthly - must audit all employees on a quarterly basis.





SEE CLINIC MANAGER MONITORING TOOL LISTED BELOW:


Butler County Dialysis Center
Clinic Manager Tracking Tool
To be brought to the monthly TQM meeting
Weekly (x8 weeks)
Item Week of 5/21/18 Week of 5/28/18 Week of 6/4/18 Week of 6/11/18 Week of 6/18/18 Week of 6/25/18 Week of 7/2/18 Week of 7/9/18
Infection Control Audit and review of the DPC audit
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Date/CM Initials
Review of records of all patients to ensure both primary and secondary access (all accesses) are being assessed at each dialysis treatment. (one day per week)
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Date/CM Initials
Clinic Manager Signature: ______________________ Date: _________


































494.30(a)(1)(i) STANDARD
IC-SINKS AVAILABLE

Name - Component - 00
A sufficient number of sinks with warm water and soap should be available to facilitate hand washing.



Observations:


Based on review of facility policy and procedure, observation, and staff (EMP) interview, the facility failed to ensure two (2) of six (6) handwashing sinks were only used for handwashing (HWS#1, & HWS#2).

Findings included:

Review of facilty policy and procedure on May 10, 2018, at 9:15 a.m. showed, "INFECTION CONTROL/BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN ... C. Work Area Restriction ... 7. Sinks need to be identified as clean, hand washing or dirty. ... Hand washing sinks are only to wash hands."

Review of facility policy on May 11, 2018, at 11:10 a.m. showed, "PRO-1-40 CHECKING CONDUCTIVITY OF DIALYSATE ... This procedure utilizes the pHoenix meter for independent measurement. ... 7. Discard dialysate sample in dirty sink."

Observation of independent conductivity testing on May 8, 2018, at 10:03 a.m. revealed EMP5 use the pHoenix meter to perform independent conductivity testing at station 13. EMP5 completed the test and walked to the clearly labeled HWS#1, and rinsed the pHoenix meter with reverse osmosis (RO) water. The contents of the rinse from the pHoenix meter were drained into the handwashing sink.

Interview with EMP5 on May 8, 2018, at 11:58 a.m. confirmed findings. At this time, EMP5 proceeded to wash his/her hands in the handwashing sink. When surveyor asked him/her if he/she washed hands in sink that is also used to rinse the contents from the pHoenix meter he/she replied, "Yes, it is a handwashing sink."

Observations on treatment floor on May 8, 2018, between 10 a.m. and 12 p.m. revealed the same arrangement at HWS#2. Staff members were observed washing their hands in this sink, and also rinsing the pHoenix meter into it.

Observation of independent conductivity testing on May 12, 2018, at approximately 10 a.m. revealed EMP16 perform independent conductivity testing at station 20. EMP16 completed the procedure, and rinsed the contents of the pHoenix meter into HWS#1.

Interview with EMP1 on May 11, 2018, at approximately 10:30 a.m. confirmed both HWS#1 and HWS#2 are both used to rinse the pHoenix meters and for employee handwashing.










Plan of Correction:

V 0114

An in-service was given to all Direct Patient Care (DPC) staff by 5-30-18 by Clinic Manager (CM) regarding the importance of preventing cross contamination when disposing of potentially contaminated solutions such as dialysate solutions. Per Policy: "Sinks need to be identified as clean, hand washing or dirty. Clean sinks are for water used to administer oral medications. Hand washing sinks are only to wash hands. Dirty/utility sinks are for cleaning blood off of clamps, draining saline bags, etc." Also per policy after drawing the conductivity (dialysate) sample: "Discard dialysate sample in dirty sink." During the in-service, emphasis was placed on not emptying potentially contaminated solutions (or any solutions) into the hand washing sinks. This includes the dialysate solution used to test the conductivity of the dialysate (or solution used to rinse the meter). Hand washing sinks are to be used for hand washing only. The solution used to test the conductivity of the dialysate or the solution used to rinse the conductivity meter must be discarded in the dirty sink. The rinse stations for the conductivity meter was changed on 5-11-18 and no longer drains into the hand washing sinks (HWS#1 and HWS#2) and now drains into the dirty sink (the rinse solution remains in a clean area). This has been added to the Infection Control Audit (IC) which is normally done monthly and will now be done weekly for 8 weeks by an assigned DPC staff member. The Clinic Manager will also complete one audit per week for 8 weeks. The first weekly Infection Control audit was conducted by a DPC staff member on 5/25/18 and by the clinic manager on 5/22/18 and will continue weekly until 100% compliance is achieved for 3 consecutive audits (minimum of 8 weeks).The Clinic Manager will ensure compliance through direct observation and through review of the Infection Control Audits. All findings will be addressed at the monthly Total Quality Management (TQM) Meeting and additional action will be taken as deemed appropriate by the committee, such as more education, continuing the weekly audits or if trends are identified, disciplinary action.



IN-SERVICE RECORD LISTED BELOW:


American Renal Associates
Butler County Dialysis Center
In-service Attendance Record

Date Initiated:

In-service: Hand Washing Sinks (V0114)

Instructor: Title:

Critique of Material Covered:

- Per Policy: "Sinks need to be identified as clean, hand washing or dirty. Clean sinks are for water used to administer oral medications. Hand washing sinks are only to wash hands. Dirty/utility sinks are for cleaning blood off of clamps, draining saline bags, etc."
- Also per policy after drawing the conductivity (dialysate) sample: "Discard dialysate sample in dirty sink."
- Staff must not empty potentially contaminated solutions (or any solutions) into the hand washing sinks. This includes the dialysate solution used to test the conductivity of the dialysate (or solution used to rinse the meter).
- Hand washing sinks are to be used for hand washing only.
- The solution used to test the conductivity of the dialysate or the solution used to rinse the conductivity meter must be discarded in the dirty sink.
- The rinse stations for the conductivity meter was changed and no longer drains into the hand washing sinks and now drains into the dirty sink (the rinse solution remains in a clean area).
- Review of the updated Infection Control Audit and increased frequency in monitoring.
Date Print Name Signature Title



INFECTION CONTROL AUDIT LISTED BELOW:



American Renal Associates
Infection Control Audit Clinic Name: Butler County Dialysis Center
To be performed at least monthly (all direct patient care staff) as a peer review or by management staff. If problems are noted, the frequency of doing this audit should be increased. Non-compliance to be addressed with staff members and audit to be brought to the monthly TQM meetings.


Date: ______________________________ Employee Signature

Station Number Comments
Staff Member
VTAG Treatment Floor Flash Tour
V122 Blood spills immediately cleaned with a 1:100 BLEACH SOL'N X2 (1:10 in OH and MI); no visible wet or dry blood (cleaned twice)
V120 HD machine transducer protectors clean and dry. If wet with blood, procedure followed.
V404 Sufficient space to prevent cross-contamination and use emergency equipment
Initiation with CVC
V116 No common tray/cart brought to dialysis station (supplies for only that patient brought to station)
V113 Gown, Mask for patient and staff covers nose and mouth, Hand hygiene, Dons clean gloves
V147 Place clean field under CVC ports
V147 "Close the catheter clamps; Disinfect CVC hubs, using an appropriate antiseptic. May perform either (or both): --External disinfection by wiping exterior caps before removing; or
--Open hub disinfection by wiping the threads and top of uncapped hub with antiseptic, removing any residue/blood
--Closed connector devices which have penetrable caps not removed, wipe outside connecting surfaces of device
"
V147 Connect sterile syringes aseptically to each port to remove indwelling solutions and/or flush with sterile saline; qualified personnel to administer heparin if ordered; wait 5 mins for heparin dwell; initiate treatment (ensure prime is dumped per procedure)
V113 Remove gloves, hand hygiene
CVC Exit Site Care
V113 Gown, Mask for patient and staff covers nose and mouth, Hand hygiene, Dons clean gloves
V147 Remove old dressing and discard without contaminating clean supplies
V147 Remove gloves, hand hygiene, don clean gloves
V147 Cleanse area around CVC exit site with antiseptic; allow to dry before applying dressing
V147 Sterile dressing applied to CVC exit site; may apply antimicrobial ointment if not contraindicated or chlorhexidine- impregnated dressing if no sensitivity
V113 Remove gloves, hand hygiene
Discontinuation of Dialysis with CVC
V113 Gown, Mask for patient and staff covers nose and mouth, Hand hygiene, Dons clean gloves
V147 Place clean field under CVC ports
Reinfuse extracorporeal circuit
V113 Remove gloves, hand hygiene, don clean gloves
V147 Close CVC clamps; Disinfect CVC connections with appropriate antiseptic. May perform one or both: --External disinfection wiping exterior of connections b/4 disconnecting blood lines; or --Open hub disinfection wiping threads and top of open CVC hubs, removing any residue/blood after disconnecting blood lines --Closed connector devices: wiping exterior of connections before disconnecting blood lines
V147 Disconnect blood lines aseptically
V147 Apply sterile port caps aseptically after post treatment protocol (applicable to closed connector devices when changed)
V116 Discard unused supplies or dedicate to that patient; no disposable supplies returned to common supplies
V113 Remove gloves, hand hygiene
Initiation with AVF/AVG
V116 No common tray/cart brought to dialysis station (supplies for only that patient brought to station)
V550 Wash skin over access with soap and water or antibacterial scrub (patient or staff may do this); for dependent patients, staff must do this before proceeding with skin antisepsis
Pro 2-80 Wash hands, don PPE
Pro 2-80 Evaluate access; Locate/palpate cannulation sites
V113 Hand hygiene; don clean gloves
V550 Apply antiseptic to skin over cannulation sites and allow to dry; sites not touched again after skin antisepsis, without repeating skin antisepsis
Pro 3-20 Insert cannulation needles; tape in place (Pro 3-40); qualified personnel to administer heparin if ordered; wait 5 mins for heparin dwell; initiate treatment (ensure prime is dumped per Procedure)
V113 Remove gloves, hand hygiene
Discontinuation with AVF / AVG
V116 No common tray/cart brought to dialysis station (supplies for only that patient brought to station)
V113 Hand hygiene, don clean gloves
Reinfuse extracorporeal circuit; disconnect bloodlines aseptically
V113 Remove gloves, hand hygiene, don clean gloves
V550 V113 Remove needles aseptically with proper engagement of safety device; needles in Sharps container not on chair table; Needle sites held with clean gauze or bandage using clean gloved hands (patient, staff or visitor) or disinfected clamps; needles disposed of at point of use
V113 Remove gloves, hand hygiene
V550 When hemostasis is achieved: Hand hygiene, don clean gloves; replace blood- soiled bandage/ gauze on needle sites;
V550 V113 Bandage/gauze on each needle site is clean & dry prior to discharge
V116 Discard unused supplies; disinfect fistula clamps and hemostats
V113 Remove gloves, hand hygiene (patient or visitor who held sites, remove gloves, hand hygiene) before touching any equipment such as the scale.
Gloves are discarded in red biohazard receptacles and not in regular trash
Cleaning and Disinfection of Dialysis Station
V122 Remove all bloodlines and disposable equipment; discard in biohazardous waste with dialyzer and bloodlines transported in a manner to prevent contamination of other surfaces
V122 Empty and disinfect prime waste receptacle if present on machine
V113 Remove gloves, hand hygiene, don clean gloves
V122 Use disinfectant-soaked cloth/wipe to visibly wet all machine top, front and side surfaces, dialysate hoses, Hansen connectors, IV Poles and outside surfaces of dialysate concentrate containers
V122 Wipe wet all internal and external surfaces of prime waste container and allow to dry
V116 V122 When chair is vacated: discard unused disposable supplies; wipe chair in Trendelenburg, and arm rests, sides of chair open if applicable fresh 1:100 bleach cloth used to visibly wet all external chair surfaces
V122 Bleach cloths are not kept on machine or chair
V122 Non-disposable items: BP cuff & tubing, TV & side arm, call button, data entry station and counters around dialysis station wiped wet with 1:100 bleach cloth
V116 Clamps cleaned of visible blood and disinfected before placing in 1:100 bleach solution for 10 minutes and then air dried before use
V113 Discard cloths/wipes; remove gloves, hand hygiene
If individual trash can used in the station, trash is emptied between patients and disinfected
General
V122 Mixing instructions for 1:100 bleach are posted
V119 Supplies are kept in designated clean areas, sufficient distance from stations to prevent contamination
V119 Supplies for next patient are not brought to the station before applicable piece of equipment (machine, chair) is cleaned/disinfected
V119 Staff do not keep pens or supplies on their person
V116 Non-disposable equipment (thermometer, pH/conductivity meter, O2 concentrator, blood glucose meter, stethoscope) brought to the dialysis station is disinfected before being returned to a clean area
V116 Disposable supplies taken to the dialysis station not used are discarded
V113 Clean glove donned completely when working with patient or machine
V115 Appropriate PPE worn and gown completely buttoned
V115 PPE removed when leaving treatment area
V113 Staff wash hands prior to entering and exiting treatment area
V114 Clean, Handwashing, and Dirty sinks used and labeled appropriately
V121 Infectious waste in Red Bags only
V122 1:100 (1:10 in OH and MI) bleach used to clean area; visible blood cleaned a 2nd time with new cloth
Treatment sheet clipboards (folder used, kept clean per facility procedure, HIPPA maintained)
B/P cuff sleeves are protecting B/P cuff on both sides
V121 Wastes/sharps are properly secured handled & disposed of properly and are not greater than full.
V120 Transducers changed when wet and between treatments. If blood on the reverse side of the transducer filter, machine is tagged and the internal transducer is checked by technical before next use.
V142 Patients with MRSA, VRE, VRSA (have own supplies)
V115 No eating, drinking or gum chewing in treatment area
V122 1:100 bleach solution made fresh daily
V122 Station vacated prior to cleaning / set up.
V228 Bi-Carts, Bi-Bags, Bicarb jugs dated (if used)
Isolation Room
V128 HBV+ patient isolated in a room or with a space of 1 station between
V131 Staff caring for HBV+ patients are HBV immune
V131 Staff not delivering care to HBV+ and HBV susceptible patients on the same shift
V130 Isolation equipment and supplies dedicated for use on HBV+ patients only and labeled "isolation" (V130)
V128 No non HBV+ patients dialyzing in the isolation room when an HBV+ patients is on the census
V130 All PPE worn on tx floor removed and hand hygiene prior to entering isolation room
V130 Appropriate PPE used when in isolation room
V130 All isolation PPE removed including facemask and hand hygiene prior to leaving room
V128 Door closed (if present) during times of potential splash or splatter
Lab tubes double bagged in biohazardous bags
Isolation waste double bagged in Red Bags
Tri Station
V403 Tubing clean and free of growth
V403 Bleach 1:100 changed daily
V403 RO water changed daily
Parenteral Medication Prep and Administration
V113 Hand hygiene
V143 Wipe stopper with alcohol or other antiseptic after removing septum cap and prior to each entry into a multi-dose vial (new pad each time)
V117 Withdraw medication into sterile syringe; Label syringe if medication not immediately administered
V117 Prepped in designated Clean area, delivered to each patient separately. Gloves removed, hands sanitized & new gloves donned before each injection.
V113 V115 Hand hygiene, don clean gloves and other PPE as indicated by potential exposure (e.g., gown and mouth/nose/eye protection if injecting into blood lines)
V143 Wipe injection port with antiseptic; inject medication (V143)
V121 Discard syringe into Sharps container (Exception: If using a needleless system with no attached needle)
V113 Remove gloves, hand hygiene
V118 Single dose vials used for one patient only and discarded
V143 Multiple dose vials are only entered with a new, sterile syringe and needle discarded within 28 days or by manufacturer's instructions (FL all only 28 days)
V117 Prepared in a clean area away from dialysis stations
V143 Proper aseptic technique used
Facility Specific
POC Patients who hold their own access wash their hands immediately after glove removal. If not and objects (scale, door) are touched, the object is cleaned with a 1:100 bleach solution, the patient educated and the education documented.
POC Dialysate solutions used to check the conductivity of the machine is only discarded in the dirty sink.
POC Hand Washing Sinks are for hand washing only.
POC All items (clipboards, pens, Phoenix meter, etc.) cleaned with a 1:100 bleach solution prior to being placed on a clean surface or in a clean area or prior to being taken into another treatment station.
POC Patints wash their vascular access with antimicrobial soap and water prior to access cannulation (hand sipes and alcohol hand sanitizers CANNOT replace soap and water).
POC Staff visualizes all cannulation sites to ensure that hemostasis has occurred and new clean gauze is applied after hemostasis.

To be completed monthly - must audit all employees on a quarterly basis.
CLINIC MANAGER TRACKING TOOL LISTED BELOW:


Butler County Dialysis Center
Clinic Manager Tracking Tool
To be brought to the monthly TQM meeting
Weekly (x8 weeks)
Item Week of 5/21/18 Week of 5/28/18 Week of 6/4/18 Week of 6/11/18 Week of 6/18/18 Week of 6/25/18 Week of 7/2/18 Week of 7/9/18
Infection Control Audit and review of the DPC audit
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Date/CM Initials
Review of records of all patients to ensure both primary and secondary access (all accesses) are being assessed at each dialysis treatment. (one day per week)
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Date/CM Initials
Clinic Manager Signature: ______________________ Date: _________



































494.30(a)(1)(i) STANDARD
IC-IF TO STATION=DISP/DEDICATE OR DISINFECT

Name - Component - 00
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.



Observations:


Based on review of facility policy and procedure, observation (OBS), and staff (EMP) interview, the facility failed to ensure staff disinfected items after use at the dialysis station for (1) of one (1) nurse practitioner (CRNP/EMP4) observed, and for one (1) of two (2) observations of independent conductivity testing (OBS#7.2).

Findings included:

Review of facilty policy and procedure on May 10, 2018, at 9:15 a.m. showed, "INFECTION CONTROL/BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN ... C. Work Area Restriction ... 10. Any item taken to the dialysis station, including those items placed on the top of the machine ... could become contaminated with blood and other body fluids and must be either used by that patient and thrown away after use or disinfected before being taken to another area. This includes the Phoenix meter."

Review of facility's "Infection Control Audit" form on May 10, 2018, at 9:15 a.m. showed, "General ... V116 Non-disposable equipment (thermometer, pH/conductivity meter ...) brought to the dialysis station is disinfected before being returned to a clean area."

Observation of EMP4 on May 8, 2018, between 10:30 and 10:45 a.m. revealed EMP4 don gloves and walk to station 12 carrying his/her own pen and clipboard with papers on it. EMP4 removed patient's flowsheet binder from the top of the hemodialysis machine while the patient was dialyzing. EMP4 held the flow sheet binder while also holding his/her clipboard while he/she wrote on it with his/her pen. EMP4 left station 12 and removed gloves and performed hand hygiene, but did not disinfect his/her clipboard or pen. EMP4 then donned another pair of gloves and walked to station 10 carrying the same clipboard while staff where initiating dialysis for the patient. EMP4 picked up flowsheet binder from the top of patient's hemodialysis machine with gloved hands. EMP4 looked at patient's flowsheets, and wrote on his/her clipboard with his/her pen. EMP4 left station 10, removed gloves and performed hand hygiene, but did not disinfect his/her clipboard and pen prior to proceeding the next dialysis station.

Interview with EMP1 on May 8, 2018, and again on May 11, 2018, at 2:30 p.m. confirmed EMP4 is new to the facility.

Observation (OBS#7.2) of independent conductivity testing on May 12, 2018, at approximately 10 a.m. revealed EMP16 take independent conductivity meter (pHoenix meter) from handwashing sink countertop (clean area) to station 20 (dirty area). EMP16 touched the hemodialysis machine and used the pHoenix meter to measure the hemodialysis machine's conductivity. EMP16 completed the procedure, wrote the result down on the patient's flow sheet, and left the dialysis station. EMP16 walked to handwashing sink wearing gloves, and placed pHoenix meter down on handwashing sink counter top without first disinfecting it.

Interview with EMP16 on May 11, 2018 after the observation confirmed findings. When EMP16 was asked if the handwashing sink countertop was a clean area he/she replied, "Technically it is."












Plan of Correction:

V 0116

An in-service was given to all Direct Patient Care (DPC) staff and EMP4 on 5-30-18 by the Clinic Manager regarding items being brought into the patient station that must be discarded at the end of the treatment or disinfected before being returned to a clean area or used on another patient. Per Policy: "Any item taken to the dialysis station, including those items placed on the top of the machine or in baskets on the side could become contaminated with blood and other body fluids and must be either used by that patient and thrown away after use or disinfected before being taken to another area. This includes the Phoenix meter and Tympanic Thermometer." During the in-service it was emphasized that the Phoenix conductivity meter must be cleaned with a 1:100 bleach solution immediately after use prior to returning the meter to a clean area (central location), prior to being placed on a clean surface (such as the hand washing sink countertop) or being used on another patient. During the in-service it was also stressed that clipboards and pens must also be disinfected immediately after leaving the patient treatment station, prior to being placed on a clean surface or prior to be taken into another patient treatment area. Whenever possible, clipboards and pens should not be taken from station to station and if they are, they must be disinfected as outlined above. This has been added to the Infection Control Audit (IC) which is normally done monthly and will now be done weekly for 8 weeks by an assigned DPC staff member. The Clinic Manager will also complete one audit per week for 8 weeks. The first weekly Infection Control audit was conducted by a DPC staff member on 5/25/18 and by the clinic manager on 5/22/18 and will continue weekly until 100% compliance is achieved for 3 consecutive audits (minimum of 8 weeks). The Clinic Manager will ensure compliance through direct observation and through review of the Infection Control Audits. All findings will be addressed at the monthly Total Quality Management (TQM) Meeting and additional action will be taken as deemed appropriate by the committee, such as more education, continuing the weekly audits or if trends are identified, disciplinary action.



IN-SERVICE RECORD LISTED BELOW:


American Renal Associates
Butler County Dialysis Center
In-service Attendance Record

Date Initiated:

In-service: Disinfection of re-usable items (V0116)

Instructor: Title:

Critique of Material Covered:

- Per Policy: Any item taken to the dialysis station, including those items placed on the top of the machine or in baskets on the side could become contaminated with blood and other body fluids and must be either used by that patient and thrown away after use or disinfected before being taken to another area. This includes the Phoenix meter and Tympanic Thermometer.
- The Phoenix conductivity meter must be cleaned with a 1:100 bleach solution immediately after use prior to returning the meter to a clean area (central location), prior to being placed on a clean surface (such as the hand washing sink countertop) or being used on another patient.
- Clipboards and pens must also be disinfected immediately after leaving the patient treatment station, prior to being placed on a clean surface or prior to be taken into another patient treatment area.
- Whenever possible, clipboards and pens should not be taken from station to station and if they are, they must be disinfected as outlined above.
- Review of the updated Infection Control Audit and increased frequency in monitoring.
Date Print Name Signature Title



INFECTION CONTROL AUDIT LISTED BELOW:


American Renal Associates
Infection Control Audit Clinic Name: Butler County Dialysis Center
To be performed at least monthly (all direct patient care staff) as a peer review or by management staff. If problems are noted, the frequency of doing this audit should be increased. Non-compliance to be addressed with staff members and audit to be brought to the monthly TQM meetings.


Date: ______________________________ Employee Signature

Station Number Comments
Staff Member
VTAG Treatment Floor Flash Tour
V122 Blood spills immediately cleaned with a 1:100 BLEACH SOL'N X2 (1:10 in OH and MI); no visible wet or dry blood (cleaned twice)
V120 HD machine transducer protectors clean and dry. If wet with blood, procedure followed.
V404 Sufficient space to prevent cross-contamination and use emergency equipment
Initiation with CVC
V116 No common tray/cart brought to dialysis station (supplies for only that patient brought to station)
V113 Gown, Mask for patient and staff covers nose and mouth, Hand hygiene, Dons clean gloves
V147 Place clean field under CVC ports
V147 "Close the catheter clamps; Disinfect CVC hubs, using an appropriate antiseptic. May perform either (or both): --External disinfection by wiping exterior caps before removing; or
--Open hub disinfection by wiping the threads and top of uncapped hub with antiseptic, removing any residue/blood
--Closed connector devices which have penetrable caps not removed, wipe outside connecting surfaces of device
"
V147 Connect sterile syringes aseptically to each port to remove indwelling solutions and/or flush with sterile saline; qualified personnel to administer heparin if ordered; wait 5 mins for heparin dwell; initiate treatment (ensure prime is dumped per procedure)
V113 Remove gloves, hand hygiene
CVC Exit Site Care
V113 Gown, Mask for patient and staff covers nose and mouth, Hand hygiene, Dons clean gloves
V147 Remove old dressing and discard without contaminating clean supplies
V147 Remove gloves, hand hygiene, don clean gloves
V147 Cleanse area around CVC exit site with antiseptic; allow to dry before applying dressing
V147 Sterile dressing applied to CVC exit site; may apply antimicrobial ointment if not contraindicated or chlorhexidine- impregnated dressing if no sensitivity
V113 Remove gloves, hand hygiene
Discontinuation of Dialysis with CVC
V113 Gown, Mask for patient and staff covers nose and mouth, Hand hygiene, Dons clean gloves
V147 Place clean field under CVC ports
Reinfuse extracorporeal circuit
V113 Remove gloves, hand hygiene, don clean gloves
V147 Close CVC clamps; Disinfect CVC connections with appropriate antiseptic. May perform one or both: --External disinfection wiping exterior of connections b/4 disconnecting blood lines; or --Open hub disinfection wiping threads and top of open CVC hubs, removing any residue/blood after disconnecting blood lines --Closed connector devices: wiping exterior of connections before disconnecting blood lines
V147 Disconnect blood lines aseptically
V147 Apply sterile port caps aseptically after post treatment protocol (applicable to closed connector devices when changed)
V116 Discard unused supplies or dedicate to that patient; no disposable supplies returned to common supplies
V113 Remove gloves, hand hygiene
Initiation with AVF/AVG
V116 No common tray/cart brought to dialysis station (supplies for only that patient brought to station)
V550 Wash skin over access with soap and water or antibacterial scrub (patient or staff may do this); for dependent patients, staff must do this before proceeding with skin antisepsis
Pro 2-80 Wash hands, don PPE
Pro 2-80 Evaluate access; Locate/palpate cannulation sites
V113 Hand hygiene; don clean gloves
V550 Apply antiseptic to skin over cannulation sites and allow to dry; sites not touched again after skin antisepsis, without repeating skin antisepsis
Pro 3-20 Insert cannulation needles; tape in place (Pro 3-40); qualified personnel to administer heparin if ordered; wait 5 mins for heparin dwell; initiate treatment (ensure prime is dumped per Procedure)
V113 Remove gloves, hand hygiene
Discontinuation with AVF / AVG
V116 No common tray/cart brought to dialysis station (supplies for only that patient brought to station)
V113 Hand hygiene, don clean gloves
Reinfuse extracorporeal circuit; disconnect bloodlines aseptically
V113 Remove gloves, hand hygiene, don clean gloves
V550 V113 Remove needles aseptically with proper engagement of safety device; needles in Sharps container not on chair table; Needle sites held with clean gauze or bandage using clean gloved hands (patient, staff or visitor) or disinfected clamps; needles disposed of at point of use
V113 Remove gloves, hand hygiene
V550 When hemostasis is achieved: Hand hygiene, don clean gloves; replace blood- soiled bandage/ gauze on needle sites;
V550 V113 Bandage/gauze on each needle site is clean & dry prior to discharge
V116 Discard unused supplies; disinfect fistula clamps and hemostats
V113 Remove gloves, hand hygiene (patient or visitor who held sites, remove gloves, hand hygiene) before touching any equipment such as the scale.
Gloves are discarded in red biohazard receptacles and not in regular trash
Cleaning and Disinfection of Dialysis Station
V122 Remove all bloodlines and disposable equipment; discard in biohazardous waste with dialyzer and bloodlines transported in a manner to prevent contamination of other surfaces
V122 Empty and disinfect prime waste receptacle if present on machine
V113 Remove gloves, hand hygiene, don clean gloves
V122 Use disinfectant-soaked cloth/wipe to visibly wet all machine top, front and side surfaces, dialysate hoses, Hansen connectors, IV Poles and outside surfaces of dialysate concentrate containers
V122 Wipe wet all internal and external surfaces of prime waste container and allow to dry
V116 V122 When chair is vacated: discard unused disposable supplies; wipe chair in Trendelenburg, and arm rests, sides of chair open if applicable fresh 1:100 bleach cloth used to visibly wet all external chair surfaces
V122 Bleach cloths are not kept on machine or chair
V122 Non-disposable items: BP cuff & tubing, TV & side arm, call button, data entry station and counters around dialysis station wiped wet with 1:100 bleach cloth
V116 Clamps cleaned of visible blood and disinfected before placing in 1:100 bleach solution for 10 minutes and then air dried before use
V113 Discard cloths/wipes; remove gloves, hand hygiene
If individual trash can used in the station, trash is emptied between patients and disinfected
General
V122 Mixing instructions for 1:100 bleach are posted
V119 Supplies are kept in designated clean areas, sufficient distance from stations to prevent contamination
V119 Supplies for next patient are not brought to the station before applicable piece of equipment (machine, chair) is cleaned/disinfected
V119 Staff do not keep pens or supplies on their person
V116 Non-disposable equipment (thermometer, pH/conductivity meter, O2 concentrator, blood glucose meter, stethoscope) brought to the dialysis station is disinfected before being returned to a clean area
V116 Disposable supplies taken to the dialysis station not used are discarded
V113 Clean glove donned completely when working with patient or machine
V115 Appropriate PPE worn and gown completely buttoned
V115 PPE removed when leaving treatment area
V113 Staff wash hands prior to entering and exiting treatment area
V114 Clean, Handwashing, and Dirty sinks used and labeled appropriately
V121 Infectious waste in Red Bags only
V122 1:100 (1:10 in OH and MI) bleach used to clean area; visible blood cleaned a 2nd time with new cloth
Treatment sheet clipboards (folder used, kept clean per facility procedure, HIPPA maintained)
B/P cuff sleeves are protecting B/P cuff on both sides
V121 Wastes/sharps are properly secured handled & disposed of properly and are not greater than full.
V120 Transducers changed when wet and between treatments. If blood on the reverse side of the transducer filter, machine is tagged and the internal transducer is checked by technical before next use.
V142 Patients with MRSA, VRE, VRSA (have own supplies)
V115 No eating, drinking or gum chewing in treatment area
V122 1:100 bleach solution made fresh daily
V122 Station vacated prior to cleaning / set up.
V228 Bi-Carts, Bi-Bags, Bicarb jugs dated (if used)
Isolation Room
V128 HBV+ patient isolated in a room or with a space of 1 station between
V131 Staff caring for HBV+ patients are HBV immune
V131 Staff not delivering care to HBV+ and HBV susceptible patients on the same shift
V130 Isolation equipment and supplies dedicated for use on HBV+ patients only and labeled "isolation" (V130)
V128 No non HBV+ patients dialyzing in the isolation room when an HBV+ patients is on the census
V130 All PPE worn on tx floor removed and hand hygiene prior to entering isolation room
V130 Appropriate PPE used when in isolation room
V130 All isolation PPE removed including facemask and hand hygiene prior to leaving room
V128 Door closed (if present) during times of potential splash or splatter
Lab tubes double bagged in biohazardous bags
Isolation waste double bagged in Red Bags
Tri Station
V403 Tubing clean and free of growth
V403 Bleach 1:100 changed daily
V403 RO water changed daily
Parenteral Medication Prep and Administration
V113 Hand hygiene
V143 Wipe stopper with alcohol or other antiseptic after removing septum cap and prior to each entry into a multi-dose vial (new pad each time)
V117 Withdraw medication into sterile syringe; Label syringe if medication not immediately administered
V117 Prepped in designated Clean area, delivered to each patient separately. Gloves removed, hands sanitized & new gloves donned before each injection.
V113 V115 Hand hygiene, don clean gloves and other PPE as indicated by potential exposure (e.g., gown and mouth/nose/eye protection if injecting into blood lines)
V143 Wipe injection port with antiseptic; inject medication (V143)
V121 Discard syringe into Sharps container (Exception: If using a needleless system with no attached needle)
V113 Remove gloves, hand hygiene
V118 Single dose vials used for one patient only and discarded
V143 Multiple dose vials are only entered with a new, sterile syringe and needle discarded within 28 days or by manufacturer's instructions (FL all only 28 days)
V117 Prepared in a clean area away from dialysis stations
V143 Proper aseptic technique used
Facility Specific
POC Patients who hold their own access wash their hands immediately after glove removal. If not and objects (scale, door) are touched, the object is cleaned with a 1:100 bleach solution, the patient educated and the education documented.
POC Dialysate solutions used to check the conductivity of the machine is only discarded in the dirty sink.
POC Hand Washing Sinks are for hand washing only.
POC All items (clipboards, pens, Phoenix meter, etc.) cleaned with a 1:100 bleach solution prior to being placed on a clean surface or in a clean area or prior to being taken into another treatment station.
POC Patints wash their vascular access with antimicrobial soap and water prior to access cannulation (hand sipes and alcohol hand sanitizers CANNOT replace soap and water).
POC Staff visualizes all cannulation sites to ensure that hemostasis has occurred and new clean gauze is applied after hemostasis.

To be completed monthly - must audit all employees on a quarterly basis.



CLINIC MANAGER MONITORING TOOL LISTED BELOW:



Butler County Dialysis Center
Clinic Manager Tracking Tool
To be brought to the monthly TQM meeting
Weekly (x8 weeks)
Item Week of 5/21/18 Week of 5/28/18 Week of 6/4/18 Week of 6/11/18 Week of 6/18/18 Week of 6/25/18 Week of 7/2/18 Week of 7/9/18
Infection Control Audit and review of the DPC audit
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Date/CM Initials
Review of records of all patients to ensure both primary and secondary access (all accesses) are being assessed at each dialysis treatment. (one day per week)
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Date/CM Initials
Clinic Manager Signature: ______________________ Date: _________




LETTER TO PATIENTS LISTED BELOW:



May 16, 2018


Dear Patient:

I am sending this letter to inform you of a practice that was brought to my attention as of a recent survey at the facility. The quality of care that we deliver to you is of utmost importance and I am asking you to help us in maintaining the best and safest care for you, our patients.

- To help prevent the potential for infection, you must wash your access site with antimicrobial soap upon entering the dialysis treatment area, prior to sitting in the dialysis chair. It is not acceptable to use sanitizing hand wipes (Sani-Hands) or an alcohol based hand sanitizer (such as Purell) in place of soap and water. If you need assistance in washing your access, please notify a staff member who will assist you.

- If you hold your own access sites at the end of your treatment, you must wear gloves and when your access has stopped bleeding and your gloves are removed, you must sanitize or wash your hands before you touch any equipment (such as the scale) and/or leave the treatment area. If your hands are visibly soiled after removing gloves, wash your hands for 15 seconds with anti-microbial soap and water, followed by thorough rinsing and use of disposable paper towels for drying. Alcohol based hand sanitizers are recommended by the CDC, if hands are not visibly soiled.

I appreciate your acceptance of these responsibilities and we will continue to strive to make this facility the best in the area.

Thank you,



Clinic Manager










































494.90(a)(5) STANDARD
POC-VASCULAR ACCESS-MONITOR/REFERRALS

Name - Component - 00
The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement.


Observations:


Based on review of facility policy and procedure, observation (OBS), and staff (EMP) interview, the facility failed to ensure staff provided arteriovenous fistula (AVF) care and assessment during initiation and termination of dialysis for four (4) of five (5) observations (OBS#4.1, OBS#4.2, OBS#5.2 & OBS#5.3).

Findings included:

Review of facility's "Infection Control Audit" form on May 10, 2018, at 9:15 a.m. showed, "Initiation with AVF ... V550 Wash skin over access with soap and water or antibacterial scrub (patient or staff may do this); for dependent patients, staff must do this before proceeding with skin antisepsis ... Discontinuation with AVF ... V550 When hemostasis [bleeding has stopped]: ... replace blood- soiled bandage/ gauze on needle sites ... Bandage/gauze on each needle site is clean & dry prior to discharge"

Review of facility policy and procedure on May 10, 2018, at 9:20 a.m. showed:

"PRO-3-95 ... OPEN SYSTEM TREATMENT TERMINATION ...- AV Fistula ... Procedure: ...15. After confirming that bleeding has stopped, apply folded clean 2x2 and band-aid or tape over each site."

"PRO-3-20 TREATMENT INITIATION - AV FISTULA ... Description: ... Patient should be instructed to wash access prior to cannulation. ... Procedure: ... 2. Instruct patient to wash access with antimicrobial soap and water."

"PRO-2-80 AV FISTULA ... EVALUATION ... Procedure: *Assist patient to access washing sink and instruct to wash access using antimicrobial soap and water. ... Post Treatment: ... 2. Verify that dressing is dry, no active bleeding noted, and tape or band-aids are secure. ... 5. Discharge patient only after hemostasis is achieved, notify charge RN for prolonged bleeding; evaluate Heparin dose, hypertension, possible stenosis"

Observation (OBS#4.1) of initiation of dialysis with an AVF on May 8, 2018, at 10:40 a.m. at station 11 revealed EMP7 wipe patient's AVF with a large alcohol based hand sanitizer towelette (Sani-Hands Disinfectant Hand Wipes). EMP7 then assessed patient's AVF with gloved hand, and then used a smaller alcohol pad to disinfect site prior to inserting needles into the patient's AVF. Interview with the patient after observation confirmed his access was not washed with soap and water at sink.

Observation (OBS#4.2) of initiation of dialysis with an AVF on May 10, 2018, at 9:40 a.m. revealed patient enter treatment area from the waiting room. Once near the scale area the patient dispensed some alcohol based disinfectant (not soap) into one hand and briefly wiped his hand over his AVF. The patient then rinsed his access with water at the sink. The patient was cannulated and dialysis was initiated. Interview with patient at 9:45 a.m. confirmed he did not use soap.

During interview with EMP1 on May 11, 2018, at 2:30 p.m. he/she noted patient has a difficult time following instructions.

Observation (OBS#5.2) of discontinuation of dialysis with and AVF on May 8, 2018, at 10:10 a.m. revealed EMP7 remove needles from patient's arm and apply gauze bandages with tape. The patient then held pressure to top needle site bandage while the bottom site bandage was clamped. Once bleeding had stopped, EMP7 peeled back bandages one at a time and looked at the needle sites. At this time blood could be visualized on both bandages. EMP7 did not change patient's bandages, but instead reapplied them and reinforced with more tape. Interview with EMP7 after observation confirmed findings.

Observation (OBS#5.3) of patient care on the treatment floor on May 8, 2018, at 1:25 p.m. revealed a patient seated at station 18 after discontinuation of dialysis with an AVF. The needles had already been removed from the patient's AVF. The patient was holding pressure to the lower needle site with her left hand while the top needle site was clamped to stop bleeding. Both sites were covered with folded gauze bandages and tape. At 1:29 p.m. the patient removed pressure from lower site and removed the clamp from the top site. The patient then applied more tape to both sites, and exited the station. The patient then walked over to scale area for an assessment. The RN (EMP10) touched and auscultated (assessed for thrill and bruit) patient's AVF through her clothing. The patient was preparing to exit treatment area into waiting room when surveyor asked patient if staff had checked her site to see if bleeding had stopped or if staff had changed her bandages. Patient confirmed no staff member assessed her site to see if bleeding had stopped, and that no one had changed her bandages. EMP10 then directed patient to come back to scale area. EMP10 said, "I better check that [AVF]." EMP10 had patient remove coat and placed his/her stethoscope over patient's bandaged AVF and once again assessed for thrill and bruit. The patient then left the treatment floor without staff assessing patient's AVF for bleeding or changing the patient's dressing.

Interview with EMP10 on May 8, 2018, at 1:36 p.m. confirmed above findings and that he/she was the charge nurse. EMP10 confirmed he/she did not check patient's AVF for bleeding, and EMP10 noted, "I normally don't do that [check to see if bleeding had stopped] but they were busy."
















Plan of Correction:

V 0550

An in-service was given to all Direct Patient Care (DPC) staff on 5-30-18 by the Clinic Manager (CM) regarding the requirement of patient's washing their vascular access prior to the staff preparing the access for cannulation. To prevent the potential for vascular related infections, it was stressed that accesses (grafts and fistulas) need to be washed with antimicrobial soap and water prior to cannulation. Per policy: "Instruct patient to wash access with antimicrobial soap and water." During the in-service it was stressed that the patient's access is to be washed with soap and water, per policy, and it is unacceptable for the patient to use hand sanitizer towelette's (Sani-Hands) or alcohol based disinfectants (including Purell hand sanitizer) in place of soap and water. Prior to the DPC staff member initiating dialysis, they must ask the patient if they have washed their access with soap and water (not wipes or hand sanitizer) and educate the patient as to why it needs to be done, if this procedure has not been completed. This education is to be documented in the patient's medical record. If the patient is unable to wash their access, then the staff should assist the patient in washing the access with soap and water. A letter will be given to all patients by the Clinic Manager instructing patients that they must wash their access with antimicrobial soap and water when entering the treatment area prior to cannulation by 5-30-18. The letter will also indicate that using hand sanitizing towelettes or alcohol based hand sanitizers is not acceptable in place of the washing with soap and water. This has been added to the Infection Control Audit (IC) which is normally done monthly and will now be done weekly for 8 weeks by an assigned DPC staff member. The Clinic Manager will also complete one audit per week for 8 weeks. The first weekly Infection Control audit was conducted by a DPC staff member on 5/25/18 and by the clinic manager on 5/22/18 and will continue weekly until 100% compliance is achieved for 3 consecutive audits (minimum of 8 weeks). The Clinic Manager will ensure compliance through direct observation and through review of the Infection Control Audits. All findings will be addressed at the monthly Total Quality Management (TQM) Meeting and additional action will be taken as deemed appropriate by the committee, such as more education, continuing the weekly audits or if trends are identified, disciplinary action.

An in-service was given to the Direct Patient Care (DPC) staff by the Clinic Manager by 5-30-18 regarding the importance of confirming hemostasis after needle removal and changing gauze on a patient's arteriovenous cannulation site after hemostasis. In order to ensure that hemostasis has been achieved, staff must visually confirm that the bleeding has stopped. The AV fistula and AV graft treatment termination procedure was reviewed with all DPC staff. Emphasis was placed on removing the gauze after all bleeding, has stopped, visualizing the site to confirm hemostasis and applying a folded clean gauze and bandaid or tape over each cannulation site. It was also stressed that when assessing the patient's access post dialysis treatment (for thrill and bruit), it must be confirmed that the access was visually checked and the gauze was changed. If not, the patient must be escorted back to their patient treatment area for visual inspection and gauze change. This has been added to the Infection Control Audit (IC) which is normally done monthly and will now be done weekly for 8 weeks by an assigned DPC staff member. The Clinic Manager will also complete one audit per week for 8 weeks. The Clinic Manager will ensure compliance through direct observation and through review of the Infection Control Audits. All findings will be addressed at the monthly Total Quality Management (TQM) Meeting and additional action will be taken as deemed appropriate by the committee, such as more education, continuing the weekly audits or if trends are identified, disciplinary action.




IN-SERVICE RECORD LISTED BELOW:




American Renal Associates
Butler County Dialysis Center
In-service Attendance Record

Date Initiated:

In-service: Access washing and access hemostasis (V0550)

Instructor: Title:

Critique of Material Covered:
Patient access washing:
- To prevent the potential for vascular related infections, patient accesses (grafts and fistulas) need to be washed with antimicrobial soap and water prior to cannulation.
- Per policy: "Instruct patient to wash access with antimicrobial soap and water."
- Patient's access is to be washed with soap and water, per policy, and it is unacceptable for the patient to use hand sanitizer towelette's (Sani-Hands) or alcohol based disinfectants (including Purell hand sanitizer) in place of soap and water.
- Prior to the DPC staff member initiating dialysis, they must ask the patient if they have washed their access with soap and water (not wipes or hand sanitizer) and educate the patient as to why it needs to be done, if this procedure has not been completed. This education is to be documented in the patient's medical record.
- If the patient is unable to wash their access, then the staff should assist the patient in washing the access with soap and water.
- Review of the letter to be distributed to all patients
- Review of the updated Infection Control Audit and increased frequency in monitoring.
Access Hemostasis/Gauze Change:

- In order to ensure that hemostasis has been achieved, staff must visually confirm that the bleeding has stopped.
- After bleeding has stopped, the gauze must be removed and the site must be visualized to confirm hemostasis. Then a clean gauze can be folded and applied to the cannulation site with a bandaid or tape, per policy.
- When assessing the patient's access post dialysis treatment (for thrill and bruit), it must be confirmed that the access was visually checked and the gauze was changed. If not, the patient must be escorted back to their patient treatment area for visual inspection and gauze change.
- Review of the policy on AV fistula and AV graft treatment termination.
- Review of the updated Infection Control Audit and increased frequency in monitoring.
Date Print Name Signature Title



LETTER TO PATIENTS LISTED BELOW:



May 16, 2018


Dear Patient:

I am sending this letter to inform you of a practice that was brought to my attention as of a recent survey at the facility. The quality of care that we deliver to you is of utmost importance and I am asking you to help us in maintaining the best and safest care for you, our patients.

- To help prevent the potential for infection, you must wash your access site with antimicrobial soap upon entering the dialysis treatment area, prior to sitting in the dialysis chair. It is not acceptable to use sanitizing hand wipes (Sani-Hands) or an alcohol based hand sanitizer (such as Purell) in place of soap and water. If you need assistance in washing your access, please notify a staff member who will assist you.

- If you hold your own access sites at the end of your treatment, you must wear gloves and when your access has stopped bleeding and your gloves are removed, you must sanitize or wash your hands before you touch any equipment (such as the scale) and/or leave the treatment area. If your hands are visibly soiled after removing gloves, wash your hands for 15 seconds with anti-microbial soap and water, followed by thorough rinsing and use of disposable paper towels for drying. Alcohol based hand sanitizers are recommended by the CDC, if hands are not visibly soiled.

I appreciate your acceptance of these responsibilities and we will continue to strive to make this facility the best in the area.

Thank you,



Clinic Manager




CLINIC MANAGER MONITORING TOOL LISTED BELOW:


Butler County Dialysis Center
Clinic Manager Tracking Tool
To be brought to the monthly TQM meeting
Weekly (x8 weeks)
Item Week of 5/21/18 Week of 5/28/18 Week of 6/4/18 Week of 6/11/18 Week of 6/18/18 Week of 6/25/18 Week of 7/2/18 Week of 7/9/18
Infection Control Audit and review of the DPC audit
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Date/CM Initials
Review of records of all patients to ensure both primary and secondary access (all accesses) are being assessed at each dialysis treatment. (one day per week)
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Discrepencies Noted:
Date/CM Initials
Clinic Manager Signature: ______________________ Date: _________



INFECTION CONTROL AUDIT LISTED BELOW:



American Renal Associates
Infection Control Audit Clinic Name: Butler County Dialysis Center
To be performed at least monthly (all direct patient care staff) as a peer review or by management staff. If problems are noted, the frequency of doing this audit should be increased. Non-compliance to be addressed with staff members and audit to be brought to the monthly TQM meetings.


Date: ______________________________ Employee Signature

Station Number Comments
Staff Member
VTAG Treatment Floor Flash Tour
V122 Blood spills immediately cleaned with a 1:100 BLEACH SOL'N X2 (1:10 in OH and MI); no visible wet or dry blood (cleaned twice)
V120 HD machine transducer protectors clean and dry. If wet with blood, procedure followed.
V404 Sufficient space to prevent cross-contamination and use emergency equipment
Initiation with CVC
V116 No common tray/cart brought to dialysis station (supplies for only that patient brought to station)
V113 Gown, Mask for patient and staff covers nose and mouth, Hand hygiene, Dons clean gloves
V147 Place clean field under CVC ports
V147 "Close the catheter clamps; Disinfect CVC hubs, using an appropriate antiseptic. May perform either (or both): --External disinfection by wiping exterior caps before removing; or
--Open hub disinfection by wiping the threads and top of uncapped hub with antiseptic, removing any residue/blood
--Closed connector devices which have penetrable caps not removed, wipe outside connecting surfaces of device
"
V147 Connect sterile syringes aseptically to each port to remove indwelling solutions and/or flush with sterile saline; qualified personnel to administer heparin if ordered; wait 5 mins for heparin dwell; initiate treatment (ensure prime is dumped per procedure)
V113 Remove gloves, hand hygiene
CVC Exit Site Care
V113 Gown, Mask for patient and staff covers nose and mouth, Hand hygiene, Dons clean gloves
V147 Remove old dressing and discard without contaminating clean supplies
V147 Remove gloves, hand hygiene, don clean gloves
V147 Cleanse area around CVC exit site with antiseptic; allow to dry before applying dressing
V147 Sterile dressing applied to CVC exit site; may apply antimicrobial ointment if not contraindicated or chlorhexidine- impregnated dressing if no sensitivity
V113 Remove gloves, hand hygiene
Discontinuation of Dialysis with CVC
V113 Gown, Mask for patient and staff covers nose and mouth, Hand hygiene, Dons clean gloves
V147 Place clean field under CVC ports
Reinfuse extracorporeal circuit
V113 Remove gloves, hand hygiene, don clean gloves
V147 Close CVC clamps; Disinfect CVC connections with appropriate antiseptic. May perform one or both: --External disinfection wiping exterior of connections b/4 disconnecting blood lines; or --Open hub disinfection wiping threads and top of open CVC hubs, removing any residue/blood after disconnecting blood lines --Closed connector devices: wiping exterior of connections before disconnecting blood lines
V147 Disconnect blood lines aseptically
V147 Apply sterile port caps aseptically after post treatment protocol (applicable to closed connector devices when changed)
V116 Discard unused supplies or dedicate to that patient; no disposable supplies returned to common supplies
V113 Remove gloves, hand hygiene
Initiation with AVF/AVG
V116 No common tray/cart brought to dialysis station (supplies for only that patient brought to station)
V550 Wash skin over access with soap and water or antibacterial scrub (patient or staff may do this); for dependent patients, staff must do this before proceeding with skin antisepsis
Pro 2-80 Wash hands, don PPE
Pro 2-80 Evaluate access; Locate/palpate cannulation sites
V113 Hand hygiene; don clean gloves
V550 Apply antiseptic to skin over cannulation sites and allow to dry; sites not touched again after skin antisepsis, without repeating skin antisepsis
Pro 3-20 Insert cannulation needles; tape in place (Pro 3-40); qualified personnel to administer heparin if ordered; wait 5 mins for heparin dwell; initiate treatment (ensure prime is dumped per Procedure)
V113 Remove gloves, hand hygiene
Discontinuation with AVF / AVG
V116 No common tray/cart brought to dialysis station (supplies for only that patient brought to station)
V113 Hand hygiene, don clean gloves
Reinfuse extracorporeal circuit; disconnect bloodlines aseptically
V113 Remove gloves, hand hygiene, don clean gloves
V550 V113 Remove needles aseptically with proper engagement of safety device; needles in Sharps container not on chair table; Needle sites held with clean gauze or bandage using clean gloved hands (patient, staff or visitor) or disinfected clamps; needles disposed of at point of use
V113 Remove gloves, hand hygiene
V550 When hemostasis is achieved: Hand hygiene, don clean gloves; replace blood- soiled bandage/ gauze on needle sites;
V550 V113 Bandage/gauze on each needle site is clean & dry prior to discharge
V116 Discard unused supplies; disinfect fistula clamps and hemostats
V113 Remove gloves, hand hygiene (patient or visitor who held sites, remove gloves, hand hygiene) before touching any equipment such as the scale.
Gloves are discarded in red biohazard receptacles and not in regular trash
Cleaning and Disinfection of Dialysis Station
V122 Remove all bloodlines and disposable equipment; discard in biohazardous waste with dialyzer and bloodlines transported in a manner to prevent contamination of other surfaces
V122 Empty and disinfect prime waste receptacle if present on machine
V113 Remove gloves, hand hygiene, don clean gloves
V122 Use disinfectant-soaked cloth/wipe to visibly wet all machine top, front and side surfaces, dialysate hoses, Hansen connectors, IV Poles and outside surfaces of dialysate concentrate containers
V122 Wipe wet all internal and external surfaces of prime waste container and allow to dry
V116 V122 When chair is vacated: discard unused disposable supplies; wipe chair in Trendelenburg, and arm rests, sides of chair open if applicable fresh 1:100 bleach cloth used to visibly wet all external chair surfaces
V122 Bleach cloths are not kept on machine or chair
V122 Non-disposable items: BP cuff & tubing, TV & side arm, call button, data entry station and counters around dialysis station wiped wet with 1:100 bleach cloth
V116 Clamps cleaned of visible blood and disinfected before placing in 1:100 bleach solution for 10 minutes and then air dried before use
V113 Discard cloths/wipes; remove gloves, hand hygiene
If individual trash can used in the station, trash is emptied between patients and disinfected
General
V122 Mixing instructions for 1:100 bleach are posted
V119 Supplies are kept in designated clean areas, sufficient distance from stations to prevent contamination
V119 Supplies for next patient are not brought to the station before applicable piece of equipment (machine, chair) is cleaned/disinfected
V119 Staff do not keep pens or supplies on their person
V116 Non-disposable equipment (thermometer, pH/conductivity meter, O2 concentrator, blood glucose meter, stethoscope) brought to the dialysis station is disinfected before being returned to a clean area
V116 Disposable supplies taken to the dialysis station not used are discarded
V113 Clean glove donned completely when working with patient or machine
V115 Appropriate PPE worn and gown completely buttoned
V115 PPE removed when leaving treatment area
V113 Staff wash hands prior to entering and exiting treatment area
V114 Clean, Handwashing, and Dirty sinks used and labeled appropriately
V121 Infectious waste in Red Bags only
V122 1:100 (1:10 in OH and MI) bleach used to clean area; visible blood cleaned a 2nd time with new cloth
Treatment sheet clipboards (folder used, kept clean per facility procedure, HIPPA maintained)
B/P cuff sleeves are protecting B/P cuff on both sides
V121 Wastes/sharps are properly secured handled & disposed of properly and are not greater than full.
V120 Transducers changed when wet and between treatments. If blood on the reverse side of the transducer filter, machine is tagged and the internal transducer is checked by technical before next use.
V142 Patients with MRSA, VRE, VRSA (have own supplies)
V115 No eating, drinking or gum chewing in treatment area
V122 1:100 bleach solution made fresh daily
V122 Station vacated prior to cleaning / set up.
V228 Bi-Carts, Bi-Bags, Bicarb jugs dated (if used)
Isolation Room
V128 HBV+ patient isolated in a room or with a space of 1 station between
V131 Staff caring for HBV+ patients are HBV immune
V131 Staff not delivering care to HBV+ and HBV susceptible patients on the same shift
V130 Isolation equipment and supplies dedicated for use on HBV+ patients only and labeled "isolation" (V130)
V128 No non HBV+ patients dialyzing in the isolation room when an HBV+ patients is on the census
V130 All PPE worn on tx floor removed and hand hygiene prior to entering isolation room
V130 Appropriate PPE used when in isolation room
V130 All isolation PPE removed including facemask and hand hygiene prior to leaving room
V128 Door closed (if present) during times of potential splash or splatter
Lab tubes double bagged in biohazardous bags
Isolation waste double bagged in Red Bags
Tri Station
V403 Tubing clean and free of growth
V403 Bleach 1:100 changed daily
V403 RO water changed daily
Parenteral Medication Prep and Administration
V113 Hand hygiene
V143 Wipe stopper with alcohol or other antiseptic after removing septum cap and prior to each entry into a multi-dose vial (new pad each time)
V117 Withdraw medication into sterile syringe; Label syringe if medication not immediately administered
V117 Prepped in designated Clean area, delivered to each patient separately. Gloves removed, hands sanitized & new gloves donned before each injection.
V113 V115 Hand hygiene, don clean gloves and other PPE as indicated by potential exposure (e.g., gown and mouth/nose/eye protection if injecting into blood lines)
V143 Wipe injection port with antiseptic; inject medication (V143)
V121 Discard syringe into Sharps container (Exception: If using a needleless system with no attached needle)
V113 Remove gloves, hand hygiene
V118 Single dose vials used for one patient only and discarded
V143 Multiple dose vials are only entered with a new, sterile syringe and needle discarded within 28 days or by manufacturer's instructions (FL all only 28 days)
V117 Prepared in a clean area away from dialysis stations
V143 Proper aseptic technique used
Facility Specific
POC Patients who hold their own access wash their hands immediately after glove removal. If not and objects (scale, door) are touched, the object is cleaned with a 1:100 bleach solution, the patient educated and the education documented.
POC Dialysate solutions used to check the conductivity of the machine is only discarded in the dirty sink.
POC Hand Washing Sinks are for hand washing only.
POC All items (clipboards, pens, Phoenix meter, etc.) cleaned with a 1:100 bleach solution prior to being placed on a clean surface or in a clean area or prior to being taken into another treatment station.
POC Patints wash their vascular access with antimicrobial soap and water prior to access cannulation (hand sipes and alcohol hand sanitizers CANNOT replace soap and water).
POC Staff visualizes all cannulation sites to ensure that hemostasis has occurred and new clean gauze is applied after hemostasis.

To be completed monthly - must audit all employees on a quarterly basis.



































494.90(a)(5) STANDARD
POC-VA MONITOR/PREVENT FAILURE/STENOSIS

Name - Component - 00
The patient's vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis.




Observations:

Based on review of facility policy, clinical records (CR) and staff (EMP) interview, the facility failed to monitor a newly created arteriovenous fistula (AVF) for symptoms of stenosis in accordance with facility policy and procedure for one (1) of one (1) clinical record reviewed with a maturing AVF (CR7).
Findings included:
Review of facility policy and procedure on May 10, 2018, at 9:20 a.m. showed, "PROCEDURE MANUAL PRO-3-25 ... Assessment: 1. Assess thrill and auscultate bruit every treatment."
"PRO-2-80 AV FISTULA ... EVALUATION ... Procedure: ... 7. Palpate access for thrill. ... 8. If you cannot palpate a thrill, auscultate with stethoscope for a bruit. If unable to hear a bruit, stop and notify the Charge RN"
Review of CR7 on May 9, 2018, at 1:30 p.m. showed patient was admitted to the facility on March 16, 2016. Her treatment prescription was for in-center dialysis 3 times per week. The patient had a maturing right brachial-basillic fistula which was created on 9/21/2017. The fistula's begin use date was 11/2/2017. Documentation from a vascular access center visit from 1/25/2018 showed that patient's fistula had failed and was not salvageable. Review of CR7's "Patient Treatment Record[s]" from 9/22/2017 to 1/24/2018 showed no assessment of the patient's AVF for 16 of 54 treatments on the following dates: 9/22, 9/27, 10/20, 10/25, 10/30, 11/15, 11/27, 11/29, 12/13, 12/22, 12/31/2017, 1/3, 1/10, 1/17, 1/19, and 1/24/2018.
Interview with EMP1 on May 10, 2018 at 2:10 p.m. confirmed above findings.
















Plan of Correction:

V 0551

An in-service was given to all DPC staff by 5-30-18 by the Clinic Manager regarding the assessments of secondary patient accesses. Procedures 3-25 (Cannulation of New AV Fistula) and Procedure 2-80 (AV Fistula Evaluation) was reviewed during the in-service. During the in-service it was stressed that in order to prevent access complications and potential access failure, both the primary and the secondary access (or all viable accesses) must be assessed with every dialysis treatment. If a patient has a Central Venous Catheter as a primary access and a graft or fistula as a secondary access, the secondary access (or all viable accesses) must be assessed for signs and symptoms of infection, pain, stenosis as well as thrill and bruit - even when not in use. All abnormal findings must be reported to the nurse in charge and the attending physician for further instruction/orders. This assessment must be included on the patient treatment records and must be done with every treatment. Additionally, all access assessments on all accesses must be included in the patient's Comprehensive Assessment and Plan of Care. A tracking tool has been developed to list all patients who have a primary and secondary access and will be maintained by the clinic manager. The Clinic Manager will review the medical records on all patients with more than one access one day per week for the next 8 weeks to ensure that all access have been assessed and will record the findings on the clinic manager monitoring tool. The first weekly medical record audit was conducted by the clinic manager on 5/22/18 and will continue weekly until 100% compliance is achieved for 3 consecutive audits (minimum of 8 weeks). The Clinic Manager will ensure compliance through direct review. This tool will be brought to the monthly Total Quality Management meeting where findings will be discussed and additional action taken as deemed appropriate such as continuing the weekly monitoring and/or disciplinary action.



IN-SERVICE RECORD LISTED BELOW:



American Renal Associates
Butler County Dialysis Center
In-service Attendance Record

Date Initiated:

In-service: Access Assessment (V0551)

Instructor: Title:

Critique of Material Covered:

- Review of procedures 3-25 (Cannulation of New AV Fistula) and Procedure 2-80 (AV Fistula Evaluation)
- In order to prevent access complications and potential access failure, both the primary and the secondary access (or all viable accesses) must be assessed with every dialysis treatment.
- If a patient has a Central Venous Cather as a primary access and a graft or fistula as a secondary access, the secondary access (or all viable accesses) must be assessed for signs and symptoms of infection, pain, stenosis as well as thrill and bruit - even when not in use.
- All abnormal findings must be reported to the nurse in charge and the attending physician for further instruction/orders.
- This assessment must be included on the patient treatment records and must be done with every treatment.
- Additionally, all access assessments on all accesses must be included in the patient's Comprehensive Assessment and Plan of Care.
- Review the Secondary Access Tool.
Date Print Name Signature Title




ACCESS TRACKING TOOL/LISTS WITH PATIENTS WITH MULTIPLE ACCESSES:


Butler County Dialysis Center
List of Patients with Multiple Accesses

Patient Name MR # Primary Access
Secondary Access Other Access (if applicable)




















* List is to be reviewed by the Clinic Manager weekly x8 weeks to ensure all access assessments are completed.
Monitroing Tool and all indicated documents were reviewed at the monthly Total Quality Management Meeting Held on _______________________.
Clinic Manager Signature: __________________________________ Date: _______________________