Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 012506	(X3) Date Survey Completed 04/13/2023
Name of Provider or Supplier Dothan Dialysis	Street Address, City, State 216 Graceland Drive, Dothan, 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 review of facility policies and procedure, Centers for Disease Control (CDC) Hand Hygiene in Healthcare Settings for use of hand sanitizer, observations and interviews with the staff it was determined the facility failed to ensure the staff and patients performed hand hygiene per facility policy, including use of the hand sanitizer/rub. This affected three of five discontinuation of dialysis with an AVF/AVG (arteriovenous fistula/graft), including Patient Identifier (PI) # 15, 10, PI # 12, two of seven cleaning and disinfection of the dialysis station observations, one of three CVC (central venous catheter) exit site care and dialysis initiation, including PI # 6, one of five parenteral medication preparation and administration observations, including PI # 6, one of four preparation of the hemodialysis (HD) machine/extracorporeal circuit observation, including PI # 9 and three of four access of dialysis with an AVF/AVG, including PI # 11, PI # 1, and PI # 9. This had the potential to negatively affect all patients being served by the facility. Findings include: Facility Policy: Infection Control for Dialysis Facilities Policy Number: 1-05-01 Revision Date: April 2023 Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. Policy: The CDC recommendations... will be followed... Hand Hygiene: 1. All teammates...will perform hand hygiene ...b. prior to gloving and immediately after removal of gloves. ...4. It is a requirement for all DaVita teammates whose primary location is working in a facility to have only natural nails and fingernail length should not extend more than 1/4 inch... 7. Disposable gloves will be worn when caring for the patient or touching the patient's equipment at the dialysis station... a. Gloves should be changed when: ...ii. When going from a "dirty" area or task to a "clean" area or task. Facility Procedure: Use of Alcohol-Based Hand Rubs Policy Number: 1-05-01 A Revision date: April 2023 Procedure ...3. Rub hands together covering all surfaces of hands and fingers until hand rub has evaporated and hands are dry. CDC Hand Hygiene in Healthcare Settings Reviewed Date: 1/8/21 ...Techniques for using alcohol-based hand sanitizer: When using alcohol-based hand sanitizer: Put product on hands and rub hands together. Cover all surfaces until hands feel dry. This should take around 20 seconds. ...Fingernail Care... Germs can live under artificial fingernails both before and after using an alcohol-based hand sanitizer and handwashing. It is recommended that healthcare providers do not wear artificial fingernails or extensions when having direct contact with patients at high risk... Facility Policy: Medication Policy Policy Number: 1-06-01 Revision Date: October 2022 Policy: ...21. An aseptic environment and aseptic technique is used when preparing medications. Careful attention to proper handwashing is performed at this time. 1. An observation was conducted on 4/11/23 at 10:02 AM at station 12 with Employee Identifier (EI) # 5, Patient Care Technician (PCT), to observe the discontinuation of dialysis and post dialysis AVF/AVG access care for PI # 15. After performing hand hygiene, EI # 5 donned gloves and used his/her left gloved hand to adjust the position of the rolling sharps container, used for multiple stations on the treatment floor, bringing it closer to him/her. EI # 5 then proceeded to remove the arterial needle from the AVF/AVG access. EI # 5 failed to remove gloves and perform hand hygiene while going from the dirty sharps container to the clean task of removing the arterial needle. An interview was conducted on 4/13/23 at 11:04 AM with EI # 1, Facility Administrator, who confirmed EI # 5 failed to remove gloves and perform hand hygiene when going from a dirty to a clean task per policy. 2. An observation was conducted on 4/11/23 at 10:45 AM with EI # 5, to observe cleaning and disinfection of dialysis station 12. EI # 5 removed the contaminated bloodlines, emptied the used prime receptacle, and proceeded to obtain the bleach cloths and clean the dialysis machine without removing gloves and performing hand hygiene prior to obtaining the bleach cloths and cleaning the machine. EI # 5 failed to follow facility policy to perform hand hygiene and change gloves when moving from a dirty to a clean task. An interview was conducted on 4/13/23 at 11:04 AM with EI # 1 who confirmed EI # 5 failed to follow facility policy for hand hygiene 3. During an observation of care on 4/11/23 at 12:02 PM at station 8 for CVC exit care and dialysis initiation, EI # 2, RN, (Registered Nurse) removed and discarded PI # 6's old CVC exit site dressings. Next, EI # 2 performed CVC exit site antisepsis with the Chloraprep swab stick. EI # 2 failed to remove his/her gloves, perform hand hygiene, and don clean gloves after removing the old CVC dressings. After EI # 2 disinfected the CVC hubs, EI # 2 attached the clean barrier to PI # 6's shirt using paper tape, removed his/her gloves, sanitized hands for five seconds, donned clean gloves, and collected lab via the CVC. EI # 2 failed to ensure his/her hands were thoroughly sanitized and dry, which takes around 20 seconds. An interview was conducted on 4/13/23 at 11:AM with EI # 1 who confirmed staff failed to follow the CDC recommendation for use of hand sanitizer and facility policy for hand hygiene during CVC exit site care. 4. An observation was conducted on 4/11/23 at 12:05 PM at station 18 with EI # 9, PCT, to observe the discontinuation of dialysis and post dialysis AVF/AVG access care for PI # 10. EI # 9 performed hand hygiene prior to the initiation of the procedure, EI # 9 was observed to have artificial nails to bilateral hands which extended 1/2 to 1 inch from the end of the finger. EI # 9 failed to clean under the artificial nails while performing hand hygiene. After performing hand hygiene, EI # 9 proceeded to don gloves and use gloved hand to adjust the position of the rolling sharps container, used for multiple stations on the treatment floor, in the station. EI # 9 proceeded to remove the needles from the AVF/AVG access. EI # 9 failed to remove gloves and perform hand hygiene after contact with contaminated sharps container prior to removing needles from AVF/AVG. An interview was conducted on 4/13/23 at 11:04 AM with EI # 1 who confirmed EI # 9 failed to remove gloves and perform hand hygiene when going from a dirty to a clean task per policy and to adhere to the facility policy for nails. 5. An observation was conducted on 4/11/23 at 12:17 PM with EI # 9, to observe a cleaning and disinfection dialysis station 16. EI # 9 removed the trash bag from the trash can then proceeded to obtain the bleach cloths and clean the treatment chair without removing gloves and performing hand hygiene before cleaning the treatment chair. An interview was conducted on 4/13/23 at 11:04 AM with EI # 1, who confirmed EI # 9 failed to remove gloves and perform hand hygiene when going from a dirty to a clean task per policy. 6. An observation of care was conducted on 4/11/23 at 12:55 PM at station 19 for discontinuation of dialysis with an AVF/AVG for PI # 12. EI # 5 sanitized his/her hands for 5 seconds, donned clean gloves, then removed PI # 12's first cannulation needle. EI # 5 failed to thoroughly sanitize hands, allow hands to dry, which takes about 20 seconds before donning clean gloves. At 1:22 PM, EI # 6, RN, removed PI # 12's second cannulation needle, removed his/her gloves, sanitized his/her hands for four seconds, opened the supply drawer and retrieved tape. EI # 6 failed to thoroughly sanitize hands, allow hands to dry, which takes about 20 seconds before donning clean gloves. An interview was conducted on 4/13/23 at 11:05 AM with EI # 1 who confirmed staff failed to follow CDC recommendations for use of hand sanitizer. 7. An observation was conducted on 4/11/23 at 1:10 PM at the medication preparation area to observe preparation and administration of parenteral medications by EI # 6 for PI # 6. EI # 6 did not perform hand hygiene prior to performing this task. An interview was conducted on 4/13/21 at 11:04 AM with EI # 1 who confirmed EI # 6 did not follow facility policy, and should have performed hand hygiene prior to preparing the medications. 8. An observation was conducted on 4/12/23 at 9:55 AM with EI # 9, to observe the preparation of the HD machine/extracorporeal circuit for PI # 9. EI # 9 performed hand hygiene and donned gloves then used gloved hand to obtain and place trash can at station 11. EI # 9 then proceded to prepare the HD machine/extracorporeal circuit without removing gloves and performing hand hygiene. An interview was conducted on 4/13/23 at 11:04 AM with EI # 1, who confirmed EI # 9 failed to remove gloves and perform hand hygiene when going from a dirty to a clean task per policy. 9. During an observation of care on 4/12/23 at 10:35 AM at station 24 for dialysis initiation with an AVF/AVG, the surveyor observed EI # 3 CCHT (Certified Clinical Hemodialysis Technician) evaluate PI # 11's access site, remove his/her gloves, sanitize hands for seven seconds, then donned clean gloves. EI # 3 failed to ensure his/her hands were thoroughly sanitized and dry, which takes around 20 seconds. After access site antisepsis, EI # 3 opened the needle packages, removed gloves, sanitized hands for four seconds, then charted at the dialysis keyboard. EI # 3 failed to ensure his/her hands were thoroughly sanitized and dry, which takes around 20 seconds, before clean gloves were donned. An interview was conducted on 4/13/23 at 11:05 AM with EI # 1 who confirmed staff failed to follow the CDC recommendations for hand sanitizer/hand rub. 10. During an observation of care on 4/12/23 at 11:00 AM at station 15 for dialysis initiation with an AVF/AVG, EI # 4, CCHT, sanitized hands for seven seconds, donned the right glove, and documented at the dialysis station keyboard. EI # 4 failed to thoroughly sanitize hands, allow hands to dry, which takes about 20 seconds before donning clean gloves. Next, EI # 4 cleaned PI # 1's access site with P.A.W.S. (Personal Antimicrobial Wipes Safetec) antibacterial wipe (in place of soap and water), then applied alcohol and ExSept antiseptic cleaner to the access site. EI # 4 failed to remove gloves and perform hand hygiene after the access site was cleaned with P.A.W.S. and prior to the ExSept antiseptic application. An interview was conducted on 4/13/23 at 11:05 AM with EI # 1 who confirmed staff failed to follow CDC recommendations for use of hand sanitizer and failed to perform hand hygiene before access site antisepsis. 11. An observation was conducted on 4/12/23 at 11:25 AM at station 11 with EI # 9, to observe the access of PI # 9's AVF/AVG for the initiation of Dialysis. During the observation, EI # 9 applied hand sanitizer to bilateral hands three times and rubbed hands together for 3 seconds, without allowing the sanitizer to fully dry. EI # 9 completed hand hygiene then obtained a stool with bare hand and rolled the stool into station 11. EI # 9 proceeded to don gloves and clean the AVF/AVG site without performing hand hygiene after using bare hand to obtain stool and prior to the donning of gloves. An interview was conducted on 4/13/23 at 11:04 AM with EI # 1, who confirmed EI # 9 failed to allow hand sanitizer to fully dry and perform hand hygiene prior to donning of gloves per the facility policy and procedure. 30952 41624