HospitalInspections.org

Based on policy review, observation, and staff interviews, the dialysis staff failed to prevent cross-contamination by failing to demonstrate strict infection control practices while caring for a dialysis patient in 2 of 2 observations (Patient #18).

Findings include:

Review of the hospital's policy "Infection Control - Acute Dialysis Unit," revised 04/2015, revealed ". . . 3) Personal protective equipment including impervious gowns, gloves and face shields, when appropriate, are worn by all personnel providing direct patient care and touching equipment. Gloves are removed and proper hand hygiene is performed between each patient contact and the station."

1. Observation during tour of the hospital's acute dialysis unit on 05/11/2017 at 1608 revealed Patient #18 was lying in bed at the end of her hemodialysis (HD) treatment. Observation revealed blood tinged extracorporeal dialysis blood lines connected to Patient #18's central venous catheter (CVC). Continued observation revealed a dialysis nurse (RN #1) entered the HD station and audibly contemplated if Patient #18 should receive another fluid bolus for low blood pressure or be taken off the HD machine. Observation revealed RN #1 made contact with the HD machine screen with her ungloved hand and moved her hand back and forth across the HD machine screen before exiting the station.

During an interview with the Manager of the Acute Dialysis Unit (NM #3), on 05/11/2017 at 1611, NM #3 stated "The machine is not clean when a patient is running."

During an interview with RN #1, on 05/11/2017 at 1615, RN #1 stated "I know it was dirty and I touched it without gloves, but she was having blood pressure issues."

2. Observation during the discontinuation of Patient #18's HD on 05/11/2017 at 1610 revealed RN #2 aseptically removed the patient's blood lines. Continued observation revealed Patient #18's HD machine alarmed as RN #2 performed open hub disinfection of the patient's CVC hubs. With the patient's open catheter hubs in one gloved hand, RN #2 reached over with her other gloved hand and silenced the HD machine alarm. Observation revealed RN #2 immediately returned to the open CVC hub disinfection with the gloved hand that touched the HD machine.

During an interview with RN #2, on 05/11/2017 at 1618, RN #2 reported the HD machine was not clean when the patient was receiving treatment. RN #2 admitted she touched the machine and returned to the patient's catheter without changing gloves. RN #2 stated she "Just wanted to silence alarm."