HospitalInspections.org

Based on observation, interview and policy review, the facility does not ensure all staff wear appropriate personal protective equipment (PPE) according to policy. This has the potential to place staff and patients at risk for infection.

Findings include:

Observations on 11/29/16 revealed at 09:45 AM Staff # 4 was discontinuing the hemodialysis treatment via catheter for Patient # 2. At 01:00 PM Staff # 14 was initiating the hemodialysis treatment via fistula for Patient # 7. Both Staff # 4 and Staff # 14 did not wear protective eyewear over their personal prescription glasses. Interview with Staff # 10 and Staff # 11 verified these findings at the time of the observations.

Observation on 11/30/16 revealed at 10:40 AM Staff # 13 was discontinuing the hemodialysis treatment via fistula for Patient # 28, but was not wearing her mask over her nose. At 10:50 AM Staff # 26 was discontinuing the hemodialysis treatment via catheter for Patient # 5, but was not wearing protective eyewear over her personal prescription glasses initially. When Staff #26 did don a face shield with mask, the mask was not covering her mouth and nose. Interview with Staff # 2 and Staff # 23 verified these findings at the time of observations.

Interview on 11/29/16 and 11/30/16 with Staff # 4 and # 8 both acknowledged they are suppose to wear gowns, eye shields, gloves, and masks when providing care to the vascular access site.

Review on 11/30/16 of facility policies revealed the following:
- "Standard Precautions- # IC.10 " last revision 01/20/15 indicates a mask & goggles or a mask with a face shield must be worn during patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions.
- "Exposure Control Plan for Occupational Exposure to Blood Borne Pathogens- #IC.22 " last revision 06/06/16 indicates regular prescription eyeglasses are not eye protection device. If personal prescription glasses are utilized, they must be equipped with permanently affixed or add-on type solid side shields.
- "Dialysis Infection Control- #IC.16" last revision 09/12/16 indicates all personnel are required to use appropriate PPE: gloves, gown/apron, mask, goggles/ face shields. Masks and goggles or face shields, gloves and apron must be worn when performing the initiation of hemodialysis, which includes cannulation of fistulas, working with central venous access, connecting blood access devices to bloodlines on the hemodialysis machine, when blood is needed to be recirculated and at the termination of hemodialysis.