Initial Comments:
Based on the findings of an onsite unannounced complaint investigation survey completed May 17, 2023, Erie Dialysis was identified to have the following standard level deficiencies. The facility was determined to be in substantial compliance with the requirements of 42 CFR, Part 494, Subparts A, B, C, and D: Conditions for Coverage for End-Stage Renal Disease Facilities (ESRD).
Plan of Correction:
494.30(a)(1) STANDARD
IC-WEAR GLOVES/HAND HYGIENE
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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 observation of the clinical area, facility policy and an interview with the facility administrator, and facility nursing staff, the facility did not ensure infection control procedure regarding glove removal and handwashing for one (1) of one (1) observations (OBS). OBS#1.
Findings include:
A review of policy 1-04-01B "Post Dialysis Vascular Access Care: Fistula/graft using safety fistula needles" on May 17, 2023 at 11:45 AM states: " 9. "Procedure" ...When the patient holds their cannulation sites, the patient will be offered gloves and performs hand hygiene when completed." 9. "Rationale"... "Gloves and hand hygiene protects patient and family members from cross contamination."
Observation of the clinical area was conducted on 5/17/23 approximately 9:00 AM-12:00 PM.
OBS#1 Station # 22, patient #2 after termination of dialysis procedure patient #2 donned glove to right hand to hold/apply pressure to cannulation sites post treatment to stop bleeding, removed glove, packed personal belongings, walked to scale, touched buttons on scale to obtain weight, walked to exit door from facility, opened door with right hand, no hand hygiene was performed by patient between termination of treatment and exiting of facility.
Interview at approximately 12:00 PM with RN2 confirmed patient #2 did not perform hand hygiene. RN2 states "we encourage them to, but they don't always listen."
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 05/26/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-04-01B "Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles" with emphasis on but not limited to: 1) When the patient holds their cannulation sites, the patient will be offered gloves and performs hand hygiene when completed. Rationale: Gloves and hand hygiene protects patient and family members from cross contamination Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
The Facility Administrator or designee will conduct infection control audits to verify patients are offered gloves when holding cannulation sites and perform hand hygiene when completed: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with monthly during internal infection control audits. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review the audit results with teammates during homeroom meetings, and with Medical Director during monthly Quality Assessment and Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
494.30(a)(1)(i) STANDARD
IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK
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Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory.
Observations:
Based on observation of the treatment area, an interview with the facility administrator, and review of facility policy and procedures the facility failed to ensure that visitors wear a cover garment which provides an impervious barrier to fluids when accompanying a patient in the treatment area for one (1) of one (1) observation (Obs). Obs#1.
Findings include:
A review of policy 1-05-01 "Infection Control For Dialysis Facilities" on May 17, 2023 at 11:00 AM states: ... " 6. Appropriate fluid resistant/fluid impervious gowns will be worn by all teammates, physicians and non-physicians (NPP) and visitors when in the treatment area."
Observation of the treatment area was conducted on May 17, 2023 from 9:00 AM-12:00 PM.
Two visitors were observed in the treatment area from approximately 9:00 AM to 11:00 AM sitting in chairs at station #7 while a patient was receiving active dialysis treatment at station #7. Neither visitor was observed wearing a cover garment that provides an impervious barrier to fluids. No garment was worn by the visitors during the time they were observed by SA while in the treatment area.
An interview with the facility administrator on May 17, 2023 at approximately 12:00PM confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 05/26/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" with the emphasis on but not limited to: 1) Appropriate fluid resistant/fluid impervious gowns will be worn by all teammates, physicians and non-physicians (NPP) and visitors when in the treatment area. Verification of attendance is evidenced by teammate's signature on the in-service sheet.
Governing body was completed on 5/24/23 to state that fluid resistant/fluid impervious gowns will be offered to law enforcement visitors for their protection from blood borne pathogens. However, given the risk of safety and their role in the clinic as guards to the inmate receiving treatment, the officers will choose if this risk outweighs the risk of not being able to get to their firearms if needed in an emergency, for the protection of clinic team and other patients receiving treatment.
While the patient continues to receive treatment in the facility, the Facility Administrator or designee will discuss this safety concern with the Medical Director during monthly Quality Assessment and Performance Improvement meetings known as Facility Health Meetings, and with Governing Body. The Facility Administrator is responsible for compliance with this plan of correction.
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