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Based on record review and interview, the hospital failed to ensure the hospital wide QAPI program included all activities in the hospital that could impact quality of patient care and patient safety. This deficient practice was evidenced by failure to include Peritoneal Dialysis (performed by patient self-administration or by patient caregivers, without staff assistance, while the patients were in the hospital) in the QAPI program.

Findings:

Review of the Medical Staff bylaws and Rules and Regulations revealed the following:
9.1.4: Quality Assessment/Performance Improvement and Patient Safety:
9.1.4.1: The Medical Staff shall participate with the Board and Administration in the performance of executive responsibilities related to the hospital quality assessment and performance improvement program. The Board, Medical Staff, and Administration shall be responsible and accountable for the following: (1)That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained. (2) That the hospital - wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety; and that all improvement actions are evaluated. (3) That clear expectations for safety are established.


In an interview on 11/26/19 at 10:55 a.m. with S2DON, she indicated the hospital currently had 4-5 patients receiving Dialysis services, including one patient receiving PD. S2DON confirmed the hospital did not have a contract for provision of peritoneal dialysis. S2DON indicated the patients or patients' family/care giver performed PD. S2DON further indicated the PD patients had to supply their own equipment. S2DON confirmed the current PD patient's wife was performing his PD and the patient would set up the PD equipment. S2DON indicated if the patient had orders from their Dialysis clinic the hospital may put them on the chart for an FYI but the hospital doesn't have anything to do with patient PD orders. S2DON explained they are not involved with keeping monitoring logs for PD patients. She said the current patient's wife is using the patient's nursing staff vital sign assessments and that is pretty much it. She reported she is not sure if they have any policies regarding patient/patient family performing PD in the hospital.

In an interview on 11/26/19 at 2:23 p.m. with S1Adm, he reported PD patients admitted for rehabilitation were aware beforehand that the hospital does not provide PD services. He indicated he does not have any paperwork on the chart, such as an attestation of competency. S1Adm indicated some PD patients can perform their own dialysis at home and family is their back-up. S1Adm reported PD patients continued with their previous standard treatment they had been on and the nephrologist consults.

In an interview on 11/26/19 at 3:50 p.m. with S4MedDir, he confirmed the PD patient/patient caregiver were responsible for providing PD because the hospital does not offer that service. He reported the hospital takes the word of the PD patient/caregiver that they are competent in providing their own PD and they document that in the very beginning in the pre-admit screening after referral from the referring facility.

In an interview on 12/2/19 at 11:24 a.m. with S5MD he reported he is aware the PD at this hospital is not staff assisted. He indicated if this hospital is the facility a PD patient requiring rehabilitation had chosen, whether for convenience or reputation, the PD patients know they have to bring their own supplies, cycler, and either they, or their caregiver have to do their exchanges.

In an interview on 12/2/19 at 1:22 p.m. with S2DON, she confirmed the patient/patient's caregiver's competency regarding infection control practice while performing PD not been assessed by the hospital staff.

In an interview on 12/2/19 at 2:00 p.m. with S3Quality, she confirmed Peritoneal Dialysis was not included in the hospital wide QAPI program.

Based on record review and interview, the hospital failed to ensure the RN supervised and evaluated the care of each patient, upon admission, and on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy. This deficient practice was evidenced by failure of the RN to monitor the patient/caregiver's competency in performing PD (Peritoneal Dialysis) and failure to provide oversight, as referenced in the hospital's PD policy, when PD treatment was performed by the patient's caregiver in the hospital for 1 (#2) of 2 (#1,#2) sampled PD patients from a total patient sample of 5 (#1-#5).

Findings:

Review of the hospital policy titled," Patient Care Assignments", Policy Number: CCS1010, revealed in part: The nursing supervisor, charge nurse, or nurse manager assigns nursing personnel to care for specific patients or groups of patients based on the employees' education, training, experience, and licensure. and the patients' acuity, problems/needs and level of intervention required. D. When a staff member is given a specific patient assignment, the staff member is responsible for the following during the assigned shift: a. observing and reporting any change in the patient's condition psychiatrically and medically, b. assisting the patient work toward his/her treatment goals, and c. documenting patient status including behaviors and interventions.

Review of the hospital policy titled, "Admission Criteria for Peritoneal Dialysis", Policy Number: CCS1008, effective date: 2/3/17, revealed in part: Policy: Nursing will provide set up assistance for a patient requiring Peritoneal Dialysis (PD). Patients will perform their own self-treatment for PD. Nursing will provide oversight per Lippincott Guidelines on Peritoneal Dialysis and assess patients receiving PD for signs and symptoms of peritonitis per Lippincott guidelines every shift.
Peritoneal Dialysis: The following is an edited reprint of information compiled and created by the national Kidney and Urologic Diseases Information Clearinghouse, a service of the National Institute of Health. PD is a kidney dialysis procedure that removes wastes, chemicals, and extra water from your body. This type of dialysis uses the lining of your abdomen, or belly, to filter your blood. This lining is called the peritoneal membrane and acts as the artificial kidney.
Possible complications: The most common problem with PD is peritonitis, a serious abdominal infection. This infection can occur if the opening where the catheter enters your body becomes infected or if contaminations occurs as the catheter is connected or disconnected from the bags. Peritonitis requires antibiotic treatment by your doctor. To avoid peritonitis, you must be careful to follow procedures exactly and to learn to recognize the early signs of peritonitis, which include fever, unusual color or cloudiness of the used fluid, and redness or pain around the catheter. Report these signs to your doctor or dialysis nurse immediately so that peritonitis can be treated quickly to avoid additional problems.
Patients admitted to this hospital requiring PD: When a patient requiring PD is admitted to this hospital, the patient will: perform self-treatment, bring any required equipment and supplies to perform PD, and sign a waiver.

Review of the selected reference titled, "Best Practices: A Guide to Excellence in Nursing Care", Philadelphia, Pa., Lippincott, Williams and Wilkins, 2003, revealed in part: If a patient with end-stage renal disease is admitted to the hospital for another health problem, you may need to perform Peritoneal Dialysis. These general guidelines apply to all types of Peritoneal Dialysis.

Do: Use strict aseptic technique, including wearing a surgical mask and having the patient wear one when changing the PD catheter dressings, manipulating the PD catheter, or opening the PD system.
Obtain the prescribed concentration and amount of dialysate.
Monitor the patient's vital signs as prescribed, especially during outflow.
Monitor and document your patient's total fluid intake and output, and record positive and negative balances after each PD exchange. Weigh him at the same time each day.

Don't: Use expired or cloudy dialysate solution.
Don't proceed with the infusion if the patient has signs and symptoms of peritonitis or infection at the insertion site.
Don't break sterile technique; peritonitis is the most common complication of PD.


Patient #1
Review of Patient #1's medical record revealed an admission date of 11/19/19 with admission diagnoses including Spinal Stenosis- cervical region, ESRD (End Stage Renal Disease), and Heel ulcer. Further review revealed Patient #1 was receiving PD (Peritoneal Dialysis).

In an interview on 11/26/19 at 2:40 p.m. with Patient #1's spouse, she reported she had been told the hospital did not provide PD services. She confirmed she had been told she would have to provide the patient's supplies and his PD machine. She indicated she had performed Patient #1's PD at home and confirmed she was performing Patient #1's PD in the hospital.


Patient #2
Review of Patient #2's medical record revealed an admission date of 7/19/19 with admission diagnoses of Critical Care Myopathy, ESRD, Diabetes Mellitus Type II, Peritonitis resolved (continue antibiotics per plan of care), and Atrial Fibrillation. Further review revealed the patient was receiving PD.

Review of Patient #2's physician's progress note, dated 7/19/19, revealed Patient #2 was a good rehab candidate and was able to do his own peritoneal dialysis and bring his own supplies.

Review of Patient #2's entire medical record, by S2DON, chart navigator, revealed no documented evidence of a signed waiver as referenced in the hospital's PD policy.

Review of Patient #2's narrative note entries from 7/19/19 - 8/15/19 revealed there were only 5 nurses' notes that had any type of reference to the patient's peritoneal dialysis treatment. The notes were as follows:

7/19/19 at 11:00 p.m.: RLQ PD catheter CDI, PD machine being set up by spouse and dialysis will be performed tonight by patient and spouse. Abdomen distended, non-tender with positive bowel sounds, non-pitting edema noted to LUE and BLE;

7/20/19 at 2:18 p.m.: Report received and assumed care. Patient alert and oriented times 4. Respirations easy unlabored. Abdomen distended with positive bowel sounds. Patient in 4 of 5 cycles of PD. He states it is running late due to being started late. PD set up by wife. Skin intact, PD site intact.

7/20/19 at 7:30 p.m.: Report received and patient care assumed. Abdomen distended but non-tender with positive bowel sounds. PD site CDI. Spouse preparing to set up machine in approximately 30 minutes. Machine remains at bedside. No apparent distress noted.

7/21/19 at 7:40 p.m.: Report received and patient care assumed. PD cath intact. PD in progress at this time. Monitor reads 1 dwell of 5. Instructed to call for assistance as needed.

7/29/19 at 7:30 p.m.: Report received, care assumed. Peritoneal dialysis in progress. Patient tolerating well. Voices no complains at this time.

Further review revealed there were no other references to the patient's PD treatments. Additional review revealed no documentation of the dialysate concentration, and no documented assessment of the appearance of the patient's drained fluid from exchanges in any of the notes. S2DON, who navigated Patient #2's electronic medical record on 11/27/19, confirmed these were the only narrative notes referencing the patient's PD treatment and further confirmed there were no assessments of the appearance of the patient's fluid and no documentation of the dialysate concentration.

In an interview on 12/3/19 at 8:43 a.m. with Patient #2's spouse, she confirmed she had been aware that she would have to perform her husband's PD because the hospital provided hemodialysis services and not PD services. Patient #2's spouse confirmed she had been aware that she was going to have to bring her husband's PD supplies and machine. Patient #2's spouse indicated the patient's nurse from his dialysis clinic had provided her with a sheet to monitor Patient #2's blood pressure, to monitor his fluid level on a daily basis, and to monitor his solution intake and output while she was performing the patient's PD in the hospital. She indicated no one had asked her anything about whether she knew how to perform PD. She said most of the nurses had told her they didn't know how to perform PD. She said when the machine was beeping, and she had stepped out of the room, the nursing staff would not touch the machine. She said at times the machine malfunctioned, for example when the lines got clogged, and an error message would come up. She said she called several times to the 24 hour help line that operated the machines and they walked her through fixing whatever the issue was. She said it happened about 3-4 times during her husband's hospitalization. Patient #2's spouse reported the hospital had not trained her for anything. She reported she had discarded her husband's waste fluid by pouring the waste fluid in the toilet. She further reported she had placed the used plastic dialysate bags in a box and had written trash on it for the housekeepers to discard. She reported she started her husband's treatment between 6:00 p.m. and 8:00 p.m. and it ran over 8 hours. Patient #2's spouse indicated the nurses assessed her husband's vital signs and she would write them down. She said the nurses usually did vital signs 2 times a day, on days and nights, and as needed. Patient #2's wife confirmed she changed the patient's access dressing and the nurses "didn't fool with it at all."

In an interview on 11/26/19 at 10:55 a.m. with S2DON, she indicated the hospital currently had 4-5 patients receiving Dialysis services. S2DON confirmed the hospital did not have a contract for provision of peritoneal dialysis. S2DON indicated the patients or patients' family/care giver performed PD. S2DON further indicated the PD patients had to supply their own equipment. S2DON confirmed there was a current PD patient and his wife was performing his PD. She reported the current patient/caregiver would set up the PD equipment. S2DON indicated if the patient had orders from their Dialysis clinic the hospital may put them on the chart for an FYI but the hospital doesn't have anything to do with patient PD orders. S2DON explained they are not involved with keeping monitoring logs for PD patients. She said the current patient's wife is using the nursing staff vital sign assessments and that is pretty much it. She reported she is not sure if they have any policies regarding patient/patient family performing PD in the hospital.

In an interview on 11/26/19 at 2:23 p.m. with S1Adm, he reported PD patients admitted for rehabilitation were aware beforehand that the hospital does not provide PD services. He indicated he does not have any paperwork on the chart, such as an attestation of competency. S1Adm indicated some PD patients can perform their own dialysis at home and family is their back-up. S1Adm reported PD patients continued with their standard treatment they were on prior to hospitalization and the nephrologist consults.

In an interview on 11/26/19 at 3:50 p.m. with S4MedDir, he confirmed the PD patient/patient caregiver were responsible for providing PD because the hospital does not offer that service. He reported the hospital takes the word of the PD patient/caregiver that they are competent in providing their own PD and they document that in the very beginning in the pre-admit screening after referral from the referring facility.

In an interview on 11/26/19 at 3:55 p.m. with S1Adm, he reported the staff nurses were not required to know and get checked off on PD. S1Adm indicated the PD patient/caregiver/family members are responsible for PD because the hospital does not provide that service. He indicated the staff nurses know standard precautions but are not performing any PD functions. He indicated the PD patients brought their own supplies and equipment when they were performing PD. He confirmed the PD patient/family is responsible for disinfection of equipment because hospital staff does not touch the equipment.

In an interview on 12/2/19 at 11:00 a.m. with S7RN, she confirmed ESRD patients in the hospital who required PD were dialyzed by the patient or the patient's caregiver/family members. S7RN reported the patients brought their own PD supplies and PD equipment. She reported nursing staff did not touch the PD equipment. S7RN confirmed she had not had any training regarding supervision of PD patients receiving dialysis and wasn't sure if there was a hospital policy regarding PD patients being dialyzed by family in the hospital.

In an interview on 12/2/19 at 11:24 a.m. with S5MD he reported he is aware the PD at this hospital is not staff assisted. He indicated if this hospital is the facility a PD patient requiring rehabilitation had chosen, whether for convenience or reputation, the PD patients know they have to bring their own supplies, cycler, and either they, or their caregiver have to do their exchanges. S5MD indicated if a PD patient who requires rehabilitation services wants staff assisted PD then they must go to a hospital. S5MD further indicated the hospital insists the PD patient must have a partner who can perform their treatment.

In an interview on 12/2/19 at 1:22 p.m. with S2DON, she presented the hospital's policy titled, "Admission Criteria for Peritoneal Dialysis", Policy Number: CCS1008, effective date: 2/3/17. S2DON confirmed she had not known about the referenced policy until S3Quality had found it after the surveyor requested the hospital's PD policy. S2DON confirmed she had not been trained regarding this PD patient policy when she had previously worked on the floor. S2DON further confirmed the staff nurses needed to be trained regarding their responsibilities in monitoring of PD patients as referenced in the policy.

Based on record review and interview, the hospital failed to ensure the nursing staff developed, and kept a current nursing care plan for each patient. This deficient practice was evidenced by failure to include all identified problems and failure to update the care plans with new problems for 3 (#2, #3, #4) of 5 (#1-#5) sampled patients reviewed for care plans.

Findings:

Review the hospital policy titled,"Nursing Process", Policy Number: CCS1008, revealed in part: The nursing process is utilized to aid in determinning the patient needs and plan of care for all patients at this hospital. Registered nurses plan, delegate, and coordinate nursing care for patients based upon individual need. A. Patient needs are identified and the plan of care is determined through the nursing process. 1. Assessment of needs, 2. Diagnosis/problem identification through analysis and synthesis of data, 3. Development of plan of care including priorities, goals, strategies, and nursing orders, 4. Implementation of care, and 5. Evaluation of patient outcome.

Patient #2
Review of Patient #2's medical record revealed an admission date of 7/19/19. Further review revealed the patient's skin was intact on admission. Additional review revealed the patient developed open, blistered areas on his buttocks/sacral area and groin during his hospitalization.

Review of Patient #2's plan of care revealed the new skin breakdown was not identified as a problem to be addressed on the plan of care.


Patient #3
Review of Patient #3's medical record revealed an admission date of 11/18/19. Further review revealed the patient's admit diagnoses included ESRD, Hepatitis, and Diabetes. Additional review revealed the patient was receiving hemodialysis treatments.

Review of Patient #3's plan of care revealed impaired fluid exchange related to ESRD and receiving Hemodialysis was not identified as a problem to be addressed on the plan of care. S2DON, chart navigator, confirmed impaired fluid exchange related to ESRD and receiving Hemodialysis was not identified as a problem on the plan of care.

Patient #4
Review of Patient #4's medical record revealed an admission date of 10/31/19. Further review revealed the patient had a healing pressure ulcer on admission that comes and goes and it was described as a Stage II Sacral wound.

Review of Patient #4's plan of care revealed potential for skin breakdown was not identified as a problem to be addressed on the plan of care. S2DON, who was navigating the patient's medical record on 11/27/19 at 3:42 p.m., confirmed potential for skin breakdown was not addressed on the plan of care. S2DON reported a meeting was held every Tuesday for updating treatment plans and for adjusting projected plans/dates for discharge destination dependent upon progress or lack of progress and/or changing needs at discharge. She acknowledged patient care plans were not complete and needed some work.

Based on record review and interview, the hospital failed to ensure a system for controlling infections and communicable diseases of patients and personnel was developed. This deficient practice is evidenced by failing to ensure patients' caregivers who were performing Peritoneal Dialysis, in the hospital, were assessed and deemed competent in hand hygiene performance during PD, donning the appropriate PPE for aseptically cleaning and changing the PD access dressing, and for disinfection of the PD cycler after use, prior to performing those actions, for 1 (2) of 2 (#1, #2) sampled PD patients reviewed from a total patient sample of 5 (#1-#5).

Findings:

Review of the hospital policy titled, "Admission Criteria for Peritoneal Dialysis", Policy Number: CCS1008, effective date: 2/3/17, revealed in part: Policy: Nursing will provide set up assistance for a patient requiring Peritoneal Dialysis (PD). Patients will perform their own self-treatment for PD. Nursing will provide oversight per Lippincott Guidelines on Peritoneal Dialysis and assess patients receiving PD for signs and symptoms of peritonitis per Lippincott guidelines every shift.
Peritoneal Dialysis: PD is a kidney dialysis procedure that removes wastes, chemicals, and extra water from your body. This type of dialysis uses the lining of your abdomen, or belly, to filter your blood. This lining is called the peritoneal membrane and acts as the artificial kidney.
Possible complications: The most common problem with PD is peritonitis, a serious abdominal infection. This infection can occur if the opening where the catheter enters your body becomes infected or if contaminations occurs as the catheter is connected or disconnected from the bags. To avoid peritonitis, you must be careful to follow procedures exactly and to learn to recognize the early signs of peritonitis, which include fever, unusual color or cloudiness of the used fluid, and redness or pain around the catheter. Report these signs to your doctor or dialysis nurse immediately so that peritonitis can be treated quickly to avoid additional problems.
Patients admitted to this hospital requiring PD: When a patient requiring PD is admitted to this hospital, the patient will: perform self-treatment, bring any required equipment and supplies to perform PD, and sign a waiver.

Review of the selected reference titled, "Best Practices: A Guide to Excellence in Nursing Care", Philadelphia, Pa., Lippincott, Williams and Wilkins, 2003, revealed in part: If a patient with end-stage renal disease is admitted to the hospital for another health problem, you may need to perform Peritoneal Dialysis. These general guidelines apply to all types of Peritoneal Dialysis.
Do: Use strict aseptic technique, including wearing a surgical mask and having the patient wear one when changing the PD catheter dressings, manipulating the PD catheter, or opening the PD system.
Don't: Use expired or cloudy dialysate solution.
Don't proceed with the infusion if the patient has signs and symptoms of peritonitis or infection at the insertion site.
Don't break sterile technique; peritonitis is the most common complication of PD.

Review of the CDC Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008, revealed " non critical surfaces (e.g. dialysis chair, bed, external surfaces of dialysis machine) should be disinfected with an EPA-registered disinfectant."

Review of Patient #2's medical record revealed an admission date of 7/19/19 with admission diagnoses of Critical Care Myopathy, ESRD, Diabetes Mellitus Type II, Peritonitis resolved (continue antibiotics per plan of care), and Atrial Fibrillation. Further review revealed the patient was receiving PD. Additional review revealed the patient's spouse was performing the patient's PD while the patient was hospitalized.

Review of Patient #2's discharge summary, dated 8/15/19, revealed the following, in part: History of present illness: Patient admitted to area emergency department on 7/5/19 with nausea, non-bloody/non-bilious vomiting and non-bloody diarrhea times 2 days, and found to have Afib with RVR ( heartrate was in the 160's).Patient was admitted to ICU for monitoring. During admit patient developed peritonitis secondary to methicillin resistant staph epidermis. Patient on Vancomycin, begun on 7/9/19, blood cultures were negative, end date of Vancomycin is 7/22/19. Patient was then placed on Ceftazidine due to Vancomycin resistance.
Physical Assessment: GI: soft, non-tender non-distended with positive bowel sounds, dialysis port in place. no erythema, no discharge.
Impression/Plan: Peritonitis: Resolved, continue antibiotics per plan of care.

Review of Patient #2's medical record revealed no documentation indicating that the patient's spouse, who was performing his PD while the patient was hospitalized, had been observed for compliance with infection control principles related to PD performance such as hand hygiene performance during PD, donning the appropriate PPE for aseptically cleaning and changing the PD access dressing, and for disinfection of the PD cycler after use, prior to performing those actions.

Review of Patient #2's discharge orders, assisted by S2DON, revealed Patient #2 was transferred to Hospital "A" upon discharge from the rehablitation hospital on 8/15/19. S2DON reported Patient #2 had only been at Hospital "A" for 3 hours on 8/15/19 before being transferred to Hospital "B".

Review of Patient #2's hospital records from Hospital "B", provided by S2DON, revealed the patient had been admitted for hypotension and encephalopathy, presumably secondary to septic shock. The patient was also found to be in cardiogenic shock.

Review of a lab culture dated 8/16/19, collected by Hospital "B" from Patient #2, revealed heavy growth of gram negative bacilli was seen on the smear and the organism identified was Klebsiella Pneumoniae. The source of the smear was peritoneal fluid drawn from the PD catheter.

Review of Patient #2's autopsy report, dated 8/19/19, indicated the patient was a 69 year old male with ESRD who presented to Hospital "B" on 8/15/19 with septic shock. Time of death was recorded on 8/16/19 at 04:07 hours. Further review revealed post mortem cultures were positive for Klebsiella Pneumoniae which was the same organism identified in the pre-mortem cultures.

Review of Patient #2's death certificate revealed the patient's cause of death was as follows: 1. ESRD, 1. Peritonitis, and 3.Sepsis.

In an interview on 12/3/19 at 8:43 a.m. with Patient #2's spouse, she confirmed she had been aware that she would have to perform her husband's PD because the hospital provided hemodialysis services and not PD services. Patient #2's spouse confirmed she had been aware that she was going to have to bring her husband's PD supplies and machine. She indicated no one had asked her anything about whether she knew how to perform PD. She said most of the nurses had told her they didn't know how to perform PD. Patient #2's spouse confirmed the hospital had not trained her for anything related to performing PD. She indicated she had discarded her husband's waste fluid by pouring the waste fluid in the toilet. She reported she had placed the used plastic dialysate bags in a box and had written trash on it for the housekeepers to discard. Patient #2's wife confirmed she changed the patient's access dressing and the nurses "didn't fool with it at all."

In an interview on 11/26/19 at 3:50 p.m. with S4MedDir, he confirmed the PD patient/patient caregiver were responsible for providing PD because the hospital does not offer that service. He reported the hospital takes the word of the PD patient/caregiver that they are competent in providing their own PD.

In an interview on 11/26/19 at 3:55 p.m. with S1Adm, he reported the staff nurses were not required to know and get checked off on PD. He indicated the staff nurses know standard precautions but are not performing any PD functions. He further indicated the PD patients brought their own supplies and equipment when they were performing PD. He confirmed the PD patient/family is responsible for disinfection of equipment because hospital staff does not touch the equipment.

In an interview on 12/2/19 at 11:00 a.m. with S7RN, she reported the patients brought their own PD supplies and PD equipment. She reported nursing staff did not touch the PD equipment. S7RN confirmed she had not had any training regarding supervision of PD patients receiving dialysis and wasn't sure if there was a hospital policy regarding PD patients being dialyzed by family in the hospital.

In an interview on 12/2/19 at 11:24 a.m. with S5MD he reported he is aware the PD at this hospital is not staff assisted. He indicated if this hospital is the facility a PD patient requiring rehabilitation had chosen, whether for convenience or reputation, the PD patients know they have to bring their own supplies, cycler, and either they, or their caregiver have to do their exchanges.

In an interview on 12/2/19 at 1:22 p.m. with S2DON, she confirmed the patient/patient's caregiver's competency regarding infection control practices while performing PD not been assessed by the hospital staff.