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Based on observation, interview, and record review the facility failed to supervise contract staff to ensure staff clean and sanitize dialysis equipment after use on a patient on contact isolation and prior to setting the machine up to dialyze another patient;

The facility failed to ensure contract staff wear gloves and gown when providing hemodialysis care for a patient on contact isolation.

This failed practice had the potential for the spread of infection to staff and patients in the facility. Citing one(1) of three (3) random observations (Staff JJ).

Findings:

Observation on the Medical /Surgical Unit on 12/18/2015 at 12:40 pm revealed the following:

Staff (JJ) Registered Nurse (RN) was observed in room 304 handling a used dialysis machine without wearing gloves or gown .There was a sign on the door to Patient (# 2's) room indicating the patient was on contact isolation.

The Surveyor asked Staff (JJ) why he was not wearing gloves and gown he stated the patient had completed her treatment and he was only cleaning up.

Observation at 12:50 pm revealed Staff (JJ) was in the Patient(#2's) room preparing the same hemodialysis machine.

There was clean blood lines, saline tubing and dialysate jugs on the machine.

The nurse was observed placing a new dialyzer on the hemodialysis machine and started priming(running saline through the lines).

There was sealed bags of saline and other supplies including a clipboard with papers on top of the dialysis machine.

The Surveyor asked Staff (JJ) what he was doing, since the patient had already completed her treatment he replied he was breaking the machine down.

The Surveyor asked him why put a new dialyzer on a machine he was breaking down, he said he was going to "toss the dialyzer." When he was asked why put a new dialyzer in the machine to toss it he replied "honestly I am preparing the dialysis machine for another patient".

The nurse was preparing the hemodialysis machine in the room of a patient who was on Contact Isolation.

During an interview on 12/18/2015 at 1:10 pm with the Unit Manager she stated Patient(#2) was on contact isolation for VRE(Vancromycin-Resistant Enterococci) bacteria in her urine.

The Manager stated the Dialysis Nurse was a contract staff and was preparing the dialysis machine to dialyze a patient in the ICU(Intensive Care Unit).

Review of the Patient(#2's) intake and output flow sheet revealed the patient had been voiding several times each day and was handling her urine and touching surfaces in her room.

Review of history and physical for Patient (# 2) dated 12/7/2015 revealed the patient was diagnosed with Neurogenic Bladder, Urinary Tract Infection with vancromycin-resistant-Enterococcus. She was still on multiple antibiotics.

Review of the facility's Infection Control Policy # 02.101 revised 10/1/08 revealed the following information:

"Isolation protocols will be observed by all acute dialysis personnel according to hospital/facility policy and procedure.

For patients positive for Hepatitis B antigen, HIV, MRSA VRE or other infectous agents these patients will be dialyzed at their bedside on dedicated hemodialysis machines.

The dedicated hemodialysis machine will be bleach disinfected according to procedure following each treatment".