Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 012501	(X3) Date Survey Completed 06/30/2021
Name of Provider or Supplier Gadsden Dialysis	Street Address, City, State 409 South First Street, Gadsden, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag

Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)

V0113

IC-WEAR GLOVES/HAND HYGIENE
CFR(s): 494.30(a)(1)

Wear disposable gloves when caring for the patient or touching the patient's equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station.

This STANDARD is not met as evidenced by:
Based on observations, review of facility policy and procedure, and staff interviews, it was determined, the staff failed to: 1. Perform hand hygiene before and between glove changes, patient and/or stations as directed per the facility policy. 2. Perform hand hygiene before touching the ChairSideSnappy keyboard. 3. Perform hand hygiene after removing gloves and obtaining clean supplies. 4. Perform hand hygiene after removing needles and removing gloves. 5. Remove gloves and performed hand hygiene per facility procedure when performing Central Venous Catheter (CVC) exit site care. 6. Perform hand hygiene after removing gloves and obtaining medications. This did affect 1of 3 observations conducted to discontinue dialysis on patients with an AVF/AVG (arteriovenous fistula/graft), 1 of 3 observations conducted to initiate dialysis and perform exit site care on patients with a CVC, and 1of 3 observations conducted to initiate dialysis and perform exit site care on patients with a CVC. This did affect Patient Identifier (PI) #5, PI # 7, PI # 6, PI #10 and 5 unsampled patients and had the potential to negatively affect all patients served by this facility. Findings include: Policy: Infection Control For Dialysis Facilities Policy Number: 1-05-01 Revised Date: October 2020 Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. Policy: The centers for Disease Control (CDC) recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients (Dialysis Precautions) will be followed when caring for all patients... Teammate Hygiene 1. Hand hygiene is to be performed upon entering the patient treatment area, prior to gloving, after removal of gloves, after contamination with blood or other infectious material, after patient and dialysis delivery system contact, between patients even if the contact is casual, before touching clean areas such as supplies and on exiting the patient treatment area... Teammate/Patient Safety 11. Teammates will wear disposable gloves when caring for patient or touching the patient's equipment at the dialysis station, and will remove gloves and wash hands or perform hand hygiene between each patient and/or station. 13. Gloves should be changed when: ...When going from a "dirty" area or task to a "clean" area or task. ...After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient's dialysis delivery system. Chairsidesnappy Terminal and Cart 71. The ChairSideSnappy cart, monitor and keyboard are considered clean areas. 72. Gloves are to be removed and hands washed or alcohol based hand rubs used before and after touching the keyboard. Title: Central Venous Catheter (CVC) with Clearguard HD (Hemodialysis) Antimicrobial End Caps Procedure Procedure Number: 1-04-02B Origination Date: April 2019 Procedure: 4. Remove old dressing and discard. 5. Observe site for signs and symptoms of infection ... 7. Remove gloves and discard. Perform hand hygiene per procedure and re-glove. 8. ...clean exit site with 2% (precent) Chlorhexidine Gluconate 70% Isopropyl Alcohol swab for a minimum 30 seconds... 1. During observations of care on 6/28/21 at 7:50 AM, the surveyor observed Employee Identifier (EI) # 5, Registered Nurse (RN), at station 1 attempt to stop bleeding around PI # 5's access site, doff gloves and donn new gloves without performing hand hygiene as directed per the facility policy. 2. During observations of care on 6/28/21 at 8:30 AM the surveyor observed EI # 6, Certified Clinical Hemodialysis Technician (CCHT), apply a glove to his/her right hand and silence the alarm on the hemodialysis machine of an unsampled patient at station 20. EI # 6 then removed his/her glove, reapplied gloves and proceeded to an unsampled patient at station 21 and touched the dialysis machine without performing hand hygiene. EI # 6 failed to perform hand hygiene between glove changes as directed per the facility policy. 3. An observation was conducted on 6/28/21 at 8:59 AM to observe EI # 6 initiate dialysis on PI # 7 at station 6 with an AVF/AVG. EI # 6 removed his/her gloves and proceeded to the clean supply drawer and retrieved clean supplies without performing hand hygiene as directed per the facility policy. 4. During observations of care on 6/28/21 at 10:00 AM the surveyor observed EI # 4, RN wearing gloves and obtaining the vital signs of an unsampled patient at station 24. EI # 4 then proceeded to station 23 and wearing the same gloves, unlocked the dialysis chair with his/her gloved hand. EI # 4 failed to remove his/her gloves between each patient and/or station. After unlocking the dialysis chair, EI # 4 removed his/her gloves and began typing on the ChairSideSnappy keyboard without performing hand hygiene as directed per the facility policy. 5. During observations of care on 6/28/21 at 10:20 AM the surveyor observed EI # 6 discontinuing dialysis on an unsampled patient at station 25. EI # 6 removed the needle and removed his/her gloves without performing hand hygiene. EI # 6 then proceeded to the ChairSideSnappy cart at station 5 and began typing on the keyboard without performing hand hygiene as directed per the facility. 6. An observation was conducted on 6/28/21 at 10:29 AM to observe EI # 4 perform exit site care and initiate dialysis on PI # 6 with a CVC at station 23. EI # 4, performed hand hygiene, donned clean gloves, removed the old dressing and discarded the old dressing and then, without performing hand hygiene, cleaned area around CVC exit site with antiseptic. Upon completion of the exit site care, EI # 4 connected sterile syringes to each port then removed his/her gloves and proceeded to the medication drawer and obtained two syringes of Heparin without performing hand hygiene as directed per the facility. 7. During observations of care on 6/28/21 at 10:45 AM, the surveyor observed EI # 8, CCHT, doff gloves, gown and face shield prior to exiting the dialysis unit. On re-entry to the dialysis unit, EI # 8 donned gown, face shield and gloves without performing hand hygiene and proceeded to secure a dressing to the left arm of an unsampled patient at station 14. EI # 8 failed to follow the facility policy for hand hygiene. 8. During observations of care on 6/29/21 at 7:50 AM, the surveyor observed EI # 4, RN provide CVC exit site care to PI # 10. EI # 4, performed hand hygiene, donned clean gloves, removed old dressing and discarded old dressing and then, without removing gloves and without performing hand hygiene, cleaned area around CVC exit site with antiseptic. An interview was conducted on 6/30/21 at 11:50 AM with EI # 1, Facility Administrator, who verified the staff failed to follow the facility policy for hand hygiene and gloving. 42144