There are  10 surveys for this facility. Please select a date to view the survey results.

Butler County Dialysis Center
Plan of Correction
Survey Date: 6/15/21 to 6/21/21


V 000

The governing body and management staff of this facility takes this deficiency statement very seriously and will ensure that these citations are corrected and that they remain in compliance. The governing body met on 6/28/2021 to review and approve the plan of correction and the tools that will keep approved plan in compliance. The in-services and tools are attached and available for review in the facility.

V 113

An in-service was initiated to all Direct Patient Care (DPC) staff on 6/28/2021, by the Clinic Manager (CM) regarding the importance of removing gloves and performing hand hygiene when going from a dirty task to a clean task to minimize the risk for cross contamination. Per Policy "Gloves must be put on before caring for a patient or touching a patient's equipment. Gloves should be changed frequently during patient care. Examples of when gloves should be changed: When soiled (blood, dialysate or other body fluids), When going from a "dirty area to a "clean" area." It was stressed during the in-service that after removing the dressing from a central venous catheter (CVC) site, gloves must be removed, hand hygiene must be performed immediately, prior to donning new gloves, and prior to continuing cleaning of the catheter site. It is never acceptable to remove the patients dressing and continue performing catheter care, with the same gloves used to remove the dirty dressing. This action had the risk of spread of infection through cross contamination. This item is on the monthly Infection Control Audit which is normally completed monthly and will be increased to weekly for 8 weeks by an assigned Direct Patient Care (DPC) staff member and by the Clinic Manger and monthly thereafter by an assigned DPC staff member. All breaks in Infection Control will be immediately addressed by the Clinic Manager. The Clinic Manager will ensure compliance through direct observation and review of the Infection Control Audits at least monthly prior to the Total Quality Management (TQM) meeting. All findings will be addressed at the monthly TQM meeting where additional action will be taken as deemed appropriate, such as additional training, continuing the weekly audits or if trends are identified, disciplinary action.

V 122
An in-service was initiated to all Direct Patient Care (DPC) staff on 6/28/2021 by the Clinic Manager regarding disinfection of all items in the patient station must be disinfected, including, the prime waste bucket on the side of the machine. Per Policy "Machines, chairs (put in trendelenburg), pillows, saline prime buckets, sharps containers, TVs, TV arms, IV poles, BP tubing, BP basket, stethoscopes, Hanson connectors, O2 concentrators, EMRs (except screen) and surrounding areas are to be cleaned with 1:100 bleach solution between every patient treatment." Also, per policy "The prime bucket is to be dumped into a dirty drain, ensure that liquid only is poured into the drain. Then rinse or wipe with 1:100 bleach solution." During the in-service it was stressed, to prevent the possibility of cross contamination, all items in the patient station must be cleaned with a cloth soaked in 1:100 bleach solution prior to bringing clean supplies into the station, such as bloodlines. This includes ensuring that any fluid in the prime waste bucket is emptied into a dirty sink, and the bucket is disinfected (inside and out), prior to bringing clean items into the station to set up for the next patient. This item has been added to the monthly infection control audit which will be done weekly for 8 weeks by an assigned Direct Patient Care (DPC) staff member and by the Clinic Manger and monthly thereafter by an assigned DPC staff member. All breaks in Infection Control will be immediately addressed by the Clinic Manager. The Clinic Manager will ensure compliance through direct observation and review of the Infection Control Audits at least monthly prior to the Total Quality Management (TQM) meeting. All findings will be addressed at the monthly TQM meeting where additional action will be taken as deemed appropriate, such as additional training, continuing the weekly audits or if trends are identified, disciplinary action.

V 130

An in-service was initiated to all Direct Patient Care (DPC) staff on 6/28/2021 by the Clinic Manager regarding the requirement for removing all personal protective equipment (PPE), including mask, when leaving isolation room. Per policy "Gloves, barrier gown, mask and safety glasses or face shield must be worn when working with an isolation patient, removed before leaving the area, and followed by thorough hand washing at a designated sink." It was stressed during the in-service that in order to reduce the risk of cross contamination, staff caring for patient's in the isolation room, must remove all PPE, including the face mask, prior to leaving the isolation room. It is unacceptable to leave the isolation room with any PPE on, such as the face mask, that was used while caring for a patient in the isolation room. This item is on the monthly infection control audit which will be done weekly for 8 weeks by an assigned Direct Patient Care (DPC) staff member and by the Clinic Manger and monthly thereafter by an assigned DPC staff member. All breaks in Infection Control will be immediately addressed by the Clinic Manager. The Clinic Manager will ensure compliance through direct observation and review of the Infection Control Audits at least monthly prior to the Total Quality Management (TQM) meeting. All findings will be addressed at the monthly TQM meeting where additional action will be taken as deemed appropriate, such as additional training, continuing the weekly audits or if trends are identified, disciplinary action.

V 637

The Corporate Clinical and Regulatory Manager (CRM) met with the Clinic Manager (CM) and the Total Quality Management (TQM) Team on 6/28/2021 regarding the requirements and process for the facility TQM Program in tracking and monitoring infection control practices of the facility. Per policy, "Incidents of infection must be documented addressed and reviewed on an ongoing basis as they occur. Data is analyzed, with trends identified and action plans developed and implemented to minimize infection transmissions and reduce future incidents." It was stressed during the in-service that the TQM meeting agenda must include the tracking and trending of facility infection control, ensuring that all incidents of infection are documented on the facilities infection tracking logs. This includes ensuring there is documentation on the infection control log of all patients, including patient CR5, that are prescribed antibiotics for foot infections, and all patients, including patient CR7, that are admitted to the hospital for infections, such as pneumonia.
The Clinic Manager is responsible for ensuring that the monthly infection tracking tool is complete and accurate, and is presented and reviewed monthly by the TQM committee. The TQM committee is responsible for reviewing all incidents of infection, including foot infections and pneumonia, to identify trends and develop action plans to minimize the incidents of infection transmission within the facility and reduce further incidents. The Clinic Manager will ensure compliance, with the above, as an active member of the TQM committee. The TQM minutes are also sent to the Corporate Clinical and Regulatory Manager monthly for review. The CRM will monitor this activity to ensure it is being done monthly.