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I. Based on document review, observations, and staff interviews, the facility failed to cover food served to patients on 3 of 3 selected nursing units (Critical Care Unit, 2 North, and 3 North) to prevent contamination of the food. The facility served an average of approximately 100 patient meals per day.

Failure to follow established sanitation standards and procedures could result in the contamination of the patient's food, potentially spreading food-borne illness to the patients.

Findings include:

1. Review of the policy "Nutritional Services Infection Prevention", last approved on 6/1/09, revealed in part, "Purpose: These guidelines are published to improve understanding of attitude toward and compliance with infection prevention ... VI. Service Standards E. All foods being displayed, held or transported are protected from contamination ... and appropriately covered ..."

2. Observations during the lunch patient meal service on 10/30/12 from 11:30 AM to 12:20 PM revealed the Nutrition Services staff prepared meals for the patients in the main kitchen, and delivered the meals to patients on the Critical Care Unit (CCU), 2 North (2 N) Unit, and 3 North (3 N) Unit. Observations revealed Nutrition Services staff placed uncovered food items (which included dinner rolls, lettuce salad, mixed fresh fruit, peaches, pears and jello) on the patient's meal tray. Observations on the nursing units revealed the patients' meal trays arrived on the nursing units in an enclosed delivery cart.

- Observation on the CCU at 11:40 AM, revealed the Hostess D and Hostess E placed the meal tray cart in a location near the entrance to the nursing unit. 7 of the 9 patients' meal trays included food items the Nutrition Services staff had failed to cover prior to transporting the tray to the nursing unit. Hostess D, Hostess E, and any available nursing staff removed the patients' meal trays from the centrally located cart, and carried the trays throughout the unit to the patient's respective rooms.

- Observation on the 2 N Unit at 12:10 PM, revealed Hostess D and Hostess E placed the meal tray cart in front of the nurses' station. 14 of the 17 patients' meal trays included food items the Nutrition Services staff had failed to cover prior to transporting the tray to the nursing unit. Hostess D, Hostess E, and any available nursing staff removed the patients' meal trays from the cart, and carried the trays throughout the unit to the patient's respective rooms.

- Observation on the 3 N Unit at 12:18 PM, revealed Hostess D and Hostess E placed the meal tray cart in front of the nurses' station. 4 of the 9 patients' meal trays included food items the Nutrition Services staff had failed to cover prior to transporting the tray to the nursing unit. Hostess D, Hostess E, and any available nursing staff removed the patients' meal trays from the cart, and carried the trays throughout the unit to the patient's respective rooms.

3. During an interview on 10/30/12 at 1:40 PM, Food service Worker C reported they covered all food items on the patient's tray if the meal tray was placed in an open cart for transportation to the nursing unit. However, if the Nutrition Services staff transported the meal trays to the nursing units in an enclosed cart, the Nutrition Services staff did not cover foods such as salads or fruits.

- During an interview on 10/30/12 at 1:45 PM, Diet Office Clerk B reported the Nutrition Services staff covered items on the patients meal trays such as salads, fruit, and jello if the Nutrition Services staff transported to meal trays to the nursing units in an enclosed cart. However, if the Nutrition Services staff transported the meal trays to the nursing units in an open cart, the Nutrition Services staff covered all the food on the patients meal trays.

- During an interview on 10/30/12 3:30 PM, the Director of Hospitality confirmed the usual practice for patient meal service included the Nutrition Services staff placing some uncovered food items (salads, jello) on the meal trays if the staff transported the trays on an enclosed cart. She reported if the staff placed the meal trays on an open cart, the staff covered all the foods.

The Director of Hospitality acknowledged at some point in the past, staff moved the meal tray delivery carts around to the each room on the unit, but the process changed related to issues with traffic and crowded halls. Instead, the staff found it easier to leave the cart in one spot and carry meal trays throughout each unit.



29852

II. Based on review of CSA's (Contracted Services A's) policies and procedures, facility policies and procedures, observations and staff interview, the CSA's staff failed to:

- perform hand hygiene prior to donning gloves and obtaining clean supplies.

- change gloves and perform hand hygiene when going from a "dirty" area or task to a "clean" area.

- remove potentially contaminated gloves and sanitize hands prior to leaving the patients dialysis station.

- remove gloves and sanitize hands prior to touching medical equipment, such as, the automated medication-dispensing unit, in the patient treatment room.

- ensure the hemodialysis (Hemodialysis is a process that cleans the blood of excess fluid and wastes by passing the blood through an artificial kidney) patients sanitized their hands after applying pressure to their vascular access sites.

Failure to ensure all CSA's staff performed hand hygiene and/or changed gloves when going from a "dirty" area or task to a "clean" area, in accordance with the CSA's policies and procedures, could potentially result in the transmission of infectious agents to patients, clean supplies,and medical equipment, such as, the automated medication dispensing unit and the nurses' station area, potentially resulting in patient and/or staff illness.

Failure to ensure patients sanitized hands after applying pressure to the vascular access (the blood vessel route that is surgically developed to enable the patient's blood to be repeatedly accessed for dialysis via venipuncture sites) could potentially result in the transmission of infectious agents/cross contaminates to other patients, visitors, staff, and/or other dialysis equipment in the patient treatment room, such as, the patient scale, wheelchairs, and potentially out into the hospital.

Failure to ensure all CSA's staff removed potentially contaminated gloves and performed hand hygiene prior to leaving the dialysis station could result in cross contamination of the bacterial contaminants when the staff's potentially contaminated gloves touched the clean supplies, the automated medication dispensing unit, and the nurses' station counter in the patient treatment room.

The facility staff reported a census of 1 acute hemodialysis patient at the time of the survey.

Findings for observations of 2 of 2 CSA's staff responsible for acute inpatient hemodialysis patient treatments (Registered Nurse [RN] N and RN Y) on 2 of 2 acute inpatient patient treatment days. (10/30/12 and 10/31/12) include:

1. Review of the CSA's policy and procedure titled, "INFECTION CONTROL PRECAUTIONS FOR DIALYSIS FACILITIES", Policy Number: 03.102, Revised: 11/20/10, included in part, "....Policy...1 Contact transmission occurs most commonly when microorganisms from a patient are transferred to the hands of a health care worker who does not comply with infection control precautions...environmental surfaces become contaminated and serve as an intermediate reservoir for pathogens: transmission can occur when a worker touched a contaminated surface then touches a patient or when a patient touches the surfaces...1. Contact transmission can be prevented by hand hygiene...glove use...hand hygiene is the most important. In addition, non sterile disposable gloves provide a protective barrier...reduce the likelihood that microorganisms present on hands of personnel will be transmitted to patients...Gloves are required whenever caring for the patient...Hands will be always be washed after gloves are removed...after touching blood...and contaminated items. The dialysis machine...considered "dirty" and gloves should be worn when touching...dialysis machine...knobs and buttons...3. Patients who hold their own sites should be gloved. Once the treatment is completed and the gloves are removed, they should...wash their hands...4. Personnel...b. Hand Washing: Hands must be washed before and after each patient contact....before putting on and after removing gloves...c. Gloves will be worn anytime the dialysis machine is touched, that includes when setting up the clean machine...e. Clean Storage: Clean Supplies stored in the treatment area...Supplies will not be removed from these clean area with contaminated gloves..."

- Review of the CSA's policy and procedure titled, "HANDWASHING TECHNIQUE" Policy Number: 03.304, revised 02/01/06 included in part, "...c. Decontaminate hands before having direct contact with patients. d. Decontaminate hands after contact with a patient's intact skin (e.g., when taking pulse or blood pressure, and lifting a patient). e. Decontaminate hands after contact with...non-intact skin and wound dressings...f. Decontaminate hands if moving from a contaminated site to a clean body site during patient care. g. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. h. Decontaminate hands after removal of gloves.

2. Observation on 10/30/12 at 10:50 AM showed RN N picked up an unlabeled container from next to the designated "dirty" sink, performed the chlorine test, and then returned the container next to the "dirty" sink. RN N reported CSA's staff used the unlabeled container to collect the RO (Reverse Osmosis) water sample from the portable RO machine (a portable water purification system that can be transported to the patient's bedside) for the chlorine test. RN N, wearing the same potentially contaminated gloves, moved to dialysis station #2 and attached the new bloodline tubing to dialysis machine (a machine that cleans the blood for the patient with kidney failure). RN N again, wearing the same gloves, moved to a common area in the patient treatment room, touched the nurses ' station counter, picked up a document, and then returned to dialysis station #2 (the area where a patient receives the dialysis treatment). RN N removed gloves, without sanitizing hands, moved to the automated medication-dispensing unit in the patient treatment room. RN N touched the identification touch pad, touched the screen, touched the open drawer, and then removed 2 multi-dose vials of heparin, potentially contaminated the 10-heparin multi-dose vials, which remained in the drawer.

- Observation at 11:00 AM showed RN N without gloves touched both the armrest and the back of Patient #3's dialysis chair at dialysis station #2. RN N without sanitizing hands, moved to the clean supply cart, removed 2 alcohol prep pads and 2 gauze 4 x 4 dressings.

- Observation at 11:15 AM showed RN N wearing a gown and no gloves, placed the stethoscope bell on Patient #3's chest and back. RN N, without sanitizing hands, moved to the nurses' station, touched the counter, picked up Patient #3's medical record, and then returned to dialysis station #2. RN N without sanitizing hands moved Patient #3 in the dialysis chair to the other side of the dialysis machine.

- Observation at 11:25 AM showed RN N touched the dialysis machine, with the same gloves, inserted Patient #3's vascular access needles. Continued observation showed RN N picked up the protective pad from under Patient #3's arm and 1 gauze pad that showed a dime size droplet of blood, and placed them in the trash. RN N removed gloves, without sanitizing hands, moved to the clean supply cart and picked up the thermometer.

- Observation at 2:35 PM showed RN N returned the blood to Patient #3 at dialysis station #2 at the end of the dialysis treatment. RN N placed a glove on Patient 3's hand, removed the fistula needles from the patient's arm and Patient #3 held pressure on the gauze over the puncture sites. At 2:48 PM, RN N removed Patient #3's gloved hand from the puncture sites, removed the glove, and without washing or sanitizing hands, RN N assisted Patient #3 to the chair side scale and Patient #3 touched the chair side scale with the same hand the patient had used to hold pressure over the puncture sites. Continued observation showed RN N assisted Patient #3 to the wheelchair and the patient then left the treatment area, still without washing or sanitizing hands. Continued observation failed to show RN N disinfected the chair side scale that Patient #3 touched.

3. Observation on 10/31/12 at 10:20 AM showed RN Y removed a blood-tinged wetted cloth from Patient #3's exit site and threw the wetted cloth in the trash. RN Y wearing the same gloves, moved to the clean supply cart, picked up the box of tourniquets, removed 1 tourniquet off the roll, and then returned the box to the clean supply cart next to 6 gauze 4 x 4 dressings, approximately 10 rolls of tape, 12 gauze 2 x 2 dressings, and 8 syringes, potentially contaminating the clean supplies. RN Y again with the same gloves, returned to Patient #3 and then connected the heparin-filled syringe to bloodline tubing (tubing used to hold a patient's blood during dialysis circulating through the hemodialysis machine) on the dialysis machine. RN Y, without removing gloves and sanitizing hands, moved to the common area, picked up a sharps container(container that is designed for the disposal of needles), returned and placed the sharps container in front of the dialysis machine at dialysis station #2. Continued observation showed RN Y dropped the tourniquet on the floor and then removed gloves; however, RN Y had a second pair of gloves on. RN Y, without removing the second pair of gloves and sanitizing hands, moved to the clean supply cart, picked up the box of tourniquets and removed 1 tourniquet off the roll. RN Y returned the box to the clean supply cart potentially contaminating the remaining clean supplies.

- Observation at 10:35 AM showed RN Y removed gloves, sanitized hands, donned gloves, and then donned a second pair of gloves. RN Y inserted Patient #3's vascular access needles. RN Y removed the prime bucket from the side of the dialysis machine at dialysis station #2, moved to the "dirty" sink, and sat the prime bucket on the "dirty" counter. RN Y removed 2 tourniquets from the prime bucket, without cleaning and disinfecting the potentially contaminated prime bucket (which sat on the "dirty" counter), RN Y returned to dialysis station #2 and attached the prime bucket to the side of the dialysis machine. RN Y removed 2 pairs of gloves, without sanitizing hands, picked up a writing pen and documented on Patient #3's flowsheet. Continued observation showed RN Y placed the end of the writing pen on the dialysis machine screen and then moved it in a tapping motion on the screen. RN Y then used the writing pen to document on Patient #3's flowsheet.

- Observation at 1:35 PM showed RN Y returned the blood to Patient #3 at dialysis station #2 at the end of the dialysis treatment. RN Y placed a glove on Patient 3's hand, removed the fistula needle from the patient's arm, and assisted Patient #3 to hold gauze over the puncture site. At 1:54 PM, RN Y removed Patient #3's gloved hand from the puncture site, removed the glove, and without washing or sanitizing hands, RN Y assisted Patient #3 to the chair side scale, Patient #3 touched the chair side scale with the same hand the patient used to hold pressure over the puncture site. Continued observation showed RN Y assisted Patient #3 to the wheelchair and the patient then left the treatment area, still without washing or sanitizing hands. Continued observation failed to show RN Y disinfected the area of the chair side scale that Patient #3 touched.

4. During an interview on 10/31/12 at 3:55 PM with the Medical Director, the CSA's Facility Administrator (FA), the CSA's Director of Nursing (DON), the CSA's Biomed Technician, the Medical Surgical Manager, and the Professional Improvement Specialist, the Medical Director reported the CSA's staff infection control practices were unacceptable and the Medical Director planned to correct the problems. The Medical Director and the Medical Surgical Manager reported CSA's staff donning 2 pairs of gloves is an unacceptable practice.


III. Based on review of the facility policies and procedures, CSA's policies and procedures, observations, and staff interviews, the CSA's staff failed to ensure the medication preparation area was clearly separated from contaminated or potentially contaminated surfaces and/or the surface was cleaned and disinfected prior to medication preparation in the patient treatment room.

Failure to separate the medication preparation area and/or supplies at a sufficient distance and from potentially contaminated areas or items and to clean and disinfect the medication preparation surface could result in contamination of these clean areas and supplies by transmission of infectious agents to objects, such as, medication filled syringes or environmental surfaces, patients, and/or staff.

The facility staff reported a census of 1 acute hemodialysis patients at the time of the survey. Findings for observation of 1 of 2 staff responsible for medication preparation (RN N) on 1 of 2 patient treatment days (10/30/12) include:

1. Review of the facility policy and procedure titled, "MEDICATION MANAGEMENT" DC#:FD2.PHAR.007, Approved 08/2012 included in part, "...C. 3. Whenever medications are prepared, staffs use appropriate techniques to avoid contamination during medication preparation...a. using clean or sterile technique...b. maintaining clean, uncluttered, and separate areas for product preparation to minimize the possibility of contamination..."

- Review of the CSA's policy and procedure titled, "INFECTION CONTROL FOR DIALYSIS FACILITIES", Policy Number: 03.102, Revised: 11/20/10, included in part, "...d. preparing medications in a clean...area...If trays are used to distribute medications, clean them before using them...2. Cleaning and Disinfection Written protocols have been established for cleaning and disinfecting surfaces and equipment in the dialysis unit..."

- Review of the CSA's policy and procedure titled, "HANDWASHING TECHNIQUE" Policy Number: 03.304, Revised 02/01/06 included in part, "...g. Decontaminate hands after contact with inanimate objects (including medical equipment)..."

2. Observation on 10/30/12 at 11:00 AM showed RN N donned gloves without sanitizing hands, took 2 heparin multi-dose vials to the clean supply cart and pulled a wooden shelf out from under the clean supply cart shelf. RN N removed 1 alcohol prep pad from the clean supply cart, wiped the stopper on both of the heparin multi-dose vials, inserted the needle of a syringe into 1 of the heparin multi-dose vials, and withdrew heparin into the syringe. RN N held the heparin filled syringe, picked up the second multi-dose heparin vial, moved to the automated medication-dispensing unit, and then removed gloves, however, RN N did not sanitize hands. RN N then touched the identification touch pad, touched the screen, and placed the open multi-dose heparin vial in the drawer, potentially contaminating the remaining 10 multi-dose heparin vials in the drawer. RN N moved to dialysis machine #2, without sanitizing hands, RN N donned gloves and attached the heparin-filled syringe to the bloodline on dialysis machine #2.

3. During an interview on 10/30/12 at 11:30 AM, RN N reported the wooden shelf is attached to the clean supply cart and designated for patient medication preparation. RN N agreed RN N did not clean and disinfect (a process that kills bacteria; a chemical or substance that destroys or slows/inhibits the growth of harmful microbes) the wooden shelf prior to Patient #3's medication preparation.

- During an interview on 10/30/12 at 3:45 PM, the Medical Surgical Manager agreed RN N did not use aseptic techniques during Patient #3's medication preparation, did not clean and disinfect the medication preparation surface, and RN N failed to follow the CSA's Infection Control and the facility Medication Management policy and procedure.


IV. Based on review of CSA's policies and procedures, observations, and staff interviews, the facility staff failed to clean and disinfect all surfaces of the dialysis machine, dialysate hoses, and B/P (blood pressure) cuff and chair side table. In addition, staff failed to clean and disinfect visible blood in accordance with the CSA's policy and procedure.

Failure to ensure staff adequately cleaned and disinfected visible blood in a timely manner and failure to ensure staff disinfected all surfaces of the dialysis machine, dialysate hoses, and chair side table could potentially expose the dialysis patients to bacterial contaminants harbored in the blood. Most hemodialysis patients have suppressed immune systems and exposure to bacterial contaminants and infectious materials could cause severe illness and/or death.

The facility staff reported a census of 1 acute hemodialysis patients at the time of the survey.
Findings for observation of 2 of 2 CSA's staff responsible for the cleaning and disinfection of the dialysis machines, equipment, and blood spills (RN N and RN Y) on 2 of 2 acute patient treatment days. (10/30/12 and 10/31/12) include:

1. Review of the CSA's policy and procedure titled, "INFECTION CONTROL PRECAUTIONS FOR DIALYSIS FACILITIES", Policy Number: 03.102, Revised: 11/20/10, included in part, "...Policy...a. For a blood spill, immediately clean the area with a cloth soaked with 1:100 dilution of household bleach...The staff...will wear gloves, and the cloth will be placed in a bucket or leak proof container and discarded. After all visible blood is cleaned, a new cloth or towel will be used to apply disinfectant and discarded...Termination of Dialysis...Machine Disinfection...Each dialysis is cleaned externally ...after each patient treatment with a bleach solution of 1:100 dilutions...At the end of the treatment, the prime bucket will be removed from the machine, emptied, washed with the bleach solution, rinsed and replaced on machine..."

2. Observation on 10/30/12 at 2:25 PM showed RN N used the disinfectant labeled "SANIMASTER 4" to wet cloths at dialysis station #2. RN N, with the wetted cloth, disinfected the top, front, and right side of the dialysis machine at dialysis station #2. However, RN N failed to disinfect all of the left side of the dialysis machine to include the basket, which held the B/P (blood pressure) cuff. RN N disinfected the B/P cuff, however, failed to disinfect the B/P cord connected to the dialysis machine. RN N placed the B/P cuff in the potentially "dirty" basket on the side of the dialysis machine. RN N failed to disinfect the hoses connected from the dialysis machine to the portable RO machine and chair side table at dialysis station #2.

- Observation at 10:50 AM showed RN Y removed the prime bucket from the side of the dialysis machine at dialysis station #2, moved to the "dirty" sink, and sat the prime bucket on the "dirty" counter. RN Y removed 2 tourniquets from the prime bucket, picked up a bottle labeled, "SANIMASTER 4", sprayed the tourniquets with the SaniMaster 4, and placed the tourniquets on a paper towel. RN Y, without cleaning and disinfecting the potentially contaminated prime bucket (that sat on the "dirty" counter) returned to dialysis station #2 and then attached the prime bucket to the side of the dialysis machine. RN Y did not clean and disinfect the prime bucket in accordance with CSA's policy and procedure.

- Observation on 10/31/12 at 11:24 AM showed RN Y attached a syringe to Patient #3's bloodline and withdrew 3 milliliters of blood. RN Y inserted 1 glucose test strip in the glucometer and held the meter. RN Y placed the needle of the syringe on the end of the test strip, pushed the plunger on the syringe and immediately the blood spurted out of the syringe and saturated the test strip, blood flowed on RN Y's gloved left hand, and blood dropped on the chair side table. RN Y with the blood-soiled glove, moved to the trash can and 3-dime size blood droplets dropped on the floor in front of the dialysis machine along with 2-dime size blood droplets dropped on the lid of the sharps container at dialysis station #2. RN Y removed the blood solid gloves; however, RN Y had a second pair of gloves on. RN Y without removing the second pair of gloves and sanitizing hands, moved to the common area in the patient treatment room and returned to dialysis station #2 with wetted cloths. RN Y used 1 wetted cloth and wiped gloved hands, the chair side table and the lid of the sharps container. However, the 3-dime size blood droplets remained on the floor in front of the dialysis machine at dialysis station #2. RN Y removed gloves and without sanitizing hands, donned 2 pairs of gloves.

During an interview on 10/31/12 at 11:38 AM, the surveyor questioned RN Y if CSA had a policy and procedure for blood spills. RN Y stated, "No we do not. I spray it first with SaniMaster 4 and wipe it up with a dry cloth."

- Observation on 10/31/12 at 1:35 PM showed the 3-dime size blood droplets remained on the floor in front of the dialysis machine at dialysis station #2. RN Y moved in front of the dialysis machine at dialysis station #2, walked through the 3 blood droplets, and smeared the droplets in front of the dialysis machine. The surveyor questioned RN Y in regards to the blood that remained on the floor since 11:24 AM. RN Y stated, "I will clean it." RN Y sprayed 1 cloth with SaniMaster 4 and wiped 2 of the 3 blood smears. Continued observation showed RN Y did not clean and disinfect the bottom of RN Y's shoes that touched the blood smear on the floor. RN Y moved to a common area in patient treatment room potentially contaminating the floor with RN Y's shoes.

- Observation on 10/31/12 at 2:05 PM showed RN Y sprayed SaniMaster 4 disinfectant on cloths. RN Y used the wetted cloths and disinfected the top and front of the dialysis machine. However, RN Y failed to disinfect the basket on the side of the dialysis machine, the back of the dialysis machine, the hoses that connect from the dialysis machine to the portable RO machine, and the chair side table. RN Y then placed the B/P cuff in the potentially "dirty" basket on the side of the dialysis machine.

3. During an interview on 10/31/12 at 2:30 PM, the Medical Surgical Manager agreed after observing the blood spill, the length of time the blood remained on the floor, and the clean up procedure, RN Y did not follow CSA's Infection Control Precautions for Dialysis Facilities. The Medical Surgical Manager and the Professional Improvement Specialist acknowledged the CSA's staff did not follow CDC Recommended Infection Control Practices, CSA's policies and procedures, and/or manufacturer's instructions to ensure adequate disinfection of the dialysis machines, blood spills, and/or equipment in the dialysis station.

- During an interview on 10/31/12 at 3:55 PM, the CSA's Biomed Technician, the CSA's Facility Administer, and the CSA's Director of Nursing agreed the manufacturer's information and the CSA's Infection Control Precautions for Dialysis Facilities policy and procedure instructed the CSA's staff to use a 1:100 bleach solution to disinfect the dialysis machine.

- During an interview on 10/31/12 at 4:10 PM, the Medical Director reported the CSA's staff infection control practices were unacceptable. The Medical Director and the Medical Surgical Manager reported CSA's staff donning 2 pairs of gloves is an unacceptable practice.

- During an interview on 11/1/12 at 10:00 AM, the Infection Control Preventionist reported the facility did not have a specific policy and procedure for blood spills, however, the staff used SaniMaster 4 disinfect to clean all blood spills. The Medical Surgical Manager acknowledged the CSA's staff did not follow the CSA's Infection Control Precautions for Dialysis Facilities policy and procedure for cleaning and disinfecting blood spills.


V. Based on review of CSA's policies and procedures, observation and staff interview, the facility failed to ensure the dialysis chairs had intact surfaces free from rips and/or tears to ensure effective cleaning and disinfection of the dialysis chair surfaces after every dialysis treatment.

Failure to maintain the chair coverings to ensure adequate cleaning and disinfection of the chairs and/or removed ripped/torn dialysis chairs in accordance with the policy and procedure could potentially result in cross contamination to the patients receiving a dialysis treatment.

The facility staff reported a census of 1 acute hemodialysis patients at the time of the survey.
Findings for 3 of 3 dialysis chairs include:

1. Review of the CSA's policy titled, "CLEANING THE DIALYSIS CHAIR" Policy Number: 03.313, Revised: 09/18/09 included in part, "...11. Report any break in the integrity of the chair cover..."

- Review of the CSA's policy titled, "INFECTION PRECAUTIONS FOR DIALYSIS FACILITIES", Policy Number: 03.102, Revised: 11/20/10, included in part, "...IV. Procedure ...4. Dialysis Chairs will be inspected for tears on a routine basis. Any chair that has a rip/tear will be pulled from service and repaired to prevent unnecessary infection control risks..."

2. Observation on 10/30/12 at 10:00 AM in the acute inpatient dialysis treatment room showed each of the 3 dialysis chairs had rips and/or tears on both arm rests along with the inside and outside of the side panels of the chairs.

3. During an interview on 10/30/12 at 4:05 PM, both the CSA's FA and CSA's DON acknowledged and verified that each of the 3 dialysis chairs showed multiple rips and/or tears on the arm rests, the inside and outside of side panels of the dialysis chairs. The CSA's DON agreed that failure to maintain the chair coverings did not ensure adequate cleaning and disinfection of the surfaces could occur.


VI. Based on review of CSA's policies and procedures, manufacturer's information, observation and staff interview, the facility failed to ensure CSA's staff's practice reflected the CSA's policies and procedures, as well as, the manufacturer's information regarding the appropriate disinfectant used to clean and disinfect the dialysis machine. In addition, the facility failed to ensure the CSA's staff used the disinfectant designated in the CSA's policies and procedures to clean the dialysis chairs, prime buckets, hemostats, and tourniquets after every dialysis treatment.

Failure to ensure the CSA's staff's practice reflected the CSA's policies and procedures and manufacturer's information related to the disinfectant used to clean and disinfect the dialysis machine could potentially result in cross contamination to the patients receiving a dialysis treatment and/or damage to the dialysis machine which may delay patients hemodialysis treatments. Failure to ensure CSA's staff used the disinfect and properly disinfected the dialysis chair, prime buckets, hemostats, and tourniquets after each dialysis treatment in accordance with the CSA's policy and procedure could potentially result in bacterial contaminants to remain on the surfaces. Bacterial contaminants that enter the patient's bloodstream could cause severe illness and/or death to the dialysis patient.

The facility staff reported a census of 1 acute hemodialysis patients at the time of the survey.
Findings for observation 2 of 2 CSA's staff (RN N and RN Y) disinfection procedures on 2 of 2 acute patient treatment days (10/30/12 and 10/31/12) include:

1. Review of the CSA's policy titled, "CLEANING THE DIALYSIS CHAIR" Policy Number: 03.313, Revised: 09/18/09 included in part, "...Equipment Cleaning Solution: Bleach 1:100 Concentration...2. Place chair in reclining position to allow for thorough cleaning. 3. Spray/apply cleaning solution onto the cloth...Make sure that you clean both the front and back of the chair, as well as the sides...4. Pull chair away...look for blood spills...Clean the chair tables to the side of the chairs and footrest...8. After bleach is thoroughly dried, wipe with a clean cloth soaked in RO water...10. Leave chair in reclined position...11. Report any break in the integrity of the chair cover..."

- Review of the CSA's policy titled, "INFECTION CONTROL PROCEDURES FOR DIALYSIS FACILITIES", Policy Number: 03.101, Revised: 05/07/12, included in part, "....IV. Procedure ...2. ii. The ch