| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 852551 | (X3) Date Survey Completed 01/15/2025 |
| Name of Provider or Supplier Duluth Dialysis | Street Address, City, State 3170 Peachtree Ind Blvd, Ste 100, Duluth, GA | |
| 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 observation, staff interview, a review of facility Policy and Procedures (P& P), and the Centers for Disease Control and Prevention (CDC) guidelines, it was determined that the Governing Body failed to ensure that the Infection Control Committee implemented P&P for prevention of cross-contamination and spread of bacteria/infections. One of two Patient Care Technicians (PCTs) ( PCT AA) observed, failed to perform hand hygiene (washed hands or used an alcohol-based hand sanitizer), after removal of contaminated gloves, between glove changes, and after touching contaminated equipment. Failure to perform infection control techniques such as hand hygiene, increased the risk for cross contamination with the potential to expose patients and staff to bloodborne pathogens in the dialysis environment. This failure had the potential to negatively affect the health and safety of 10 of 10 patients seated at Station (S) 1, S2, S3, S6, S7, S8, S9, S11, S12, and S15, who were undergoing hemodialysis treatment at the time of this observation. The facility in-center hemodialysis census was 32. Findings include: During observation in the Patient Treatment Room on 1/13/25 between 10:55 a.m. and 12:16 p.m., the following was revealed: - At 11:02 a.m., PCT AA was observed preparing P#7 for the initiation of hemodialysis treatment at S3 while she wore gloves. Without removing her gloves, PCT AA went to S2 and silenced P#6's hemodialysis machine. PCT AA then went back to S3 and continued with P#7's initiation of treatment while she wore the same contaminated gloves. When PCT AA removed her gloves, she donned clean gloves without performing hand hygiene. - At 11:06 a.m., PCT AA was observed with a new pair of clean gloves on. PCT AA silenced the machine at S5 and immediately proceeded to S2 and silenced P#6's machine while she wore the same pair of gloves used at S5. -At 11:12 a.m., PCT AA silenced P#6's machine at S2 with ungloved hand. Without performing hand hygiene, PCT AA donned clean gloves and cannulated P#7 at S3 and initiated P#7's dialysis treatment. When finished, she removed her gloves and did not perform hand hygiene. - PCT AA donned a clean pair of gloves and silenced the machine at S5. PCT AA then proceeded to the clean supply area and obtained one of the clean clamps while she wore contaminated gloves. She then proceeded to S3 and clamped P#7's bloodlines to his shirt. During an interview on 1/15/25 at 12:16 p.m., PCT AA acknowledged the above observations and stated that she did not wash her hands between every glove change. PCT AA stated she was aware that she was supposed to change gloves anytime when her gloves are soiled and before moving to another patient. PCT AA also stated she will get better at performing infection control techniques because she knew she was supposed to perform hand hygiene between each glove change. - A review of facility Policy: 1-05-01, titled, "Infection Control For Dialysis Facilities" with latest revision date of April 2023, stated: Hand Hygiene 1. All teammates, Physicians and Non-Physician (NNP) will perform hand hygiene b. prior to gloving and immediately and after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse PPE 7a. Gloves should changed when: i. When soiled with blood, dialysate or other body fluids ii. When going from a "dirty" area or task to a "clean" area or task iii. When moving from a contaminated body site to a clean body site of the same patient; and iv. After touching one patient or their dialysis delivery system and before arriving to care for another patient or touching another patient's dialysis delivery system According to CDC, even with glove use, hand hygiene is necessary after glove removal because hands can become contaminated through small defects in gloves and from the outer surface of gloves during glove removal ... |