HospitalInspections.org

Based on observation, staff interview and facility document review, the facility staff failed to:
1. Ensure staff followed proper infection control practices for hand hygiene, cleaning of equipment, including the disinfection of dialysis bath containers if not dedicated to one patient.

2. Ensure the policy and procedures for the management of Hepatitis B testing and vaccination for dialysis patients was followed for two (2) of 7 (seven) patients who required dialysis treatment. Patients # 2 and #12.

3. Ensure Dialysis bath containers, if not dedicated to single use, were cleaned appropriately before being removed from the patient room and/or placed in storage area with other containers.

4. Ensure staff followed proper procedure for hand hygiene during glucose testing, cleaning of dialysis equipment and management of supplies.

5. Ensure the Employee Health Program followed the recommendations of the CDC regarding staff immunizations/screenings to protect patients from exposure.

6. Ensure Housekeeping/Environmental services followed proper procedures for cleaning and disinfection of patient rooms.

7. Ensure proper cleaning of therapy equipment including ensuring surfaces were intact to allow for proper sanitization/disinfection between patients.

The findings included:

1. During observations made in the patient care areas, the following was observed by the surveyor:

On 4/24/18 at 12:45 p.m. the surveyor observed Staff Member #10 perform dialysis treatment for Patient #3 who was in contact precautions isolation. The signage at the door indicated "Special Enteric Precautions". At the completion of treatment, Staff Member #10 was observed to clean the dialysis machine. The surveyor observed as the Staff member utilized disinfectant cloths obtained from a canister with a purple top. During the cleaning process, the Staff Member failed to thoroughly clean the machine. He/She did not clean the top of the attached IV pole, nor the laminated card that was hanging from the pole. The prime bucket was wiped on the outside and replaced, but was not rinsed and the inside cleaned. The Staff Member was observed to drop the disinfectant cloth on the floor twice and picked the cloth from the floor and continued to use it to clean the machine. Staff Member #10 indicated the patient was on C-diff precautions. After completing the "cleaning" of the machine, Staff Member #10 took the machine into another patient room for use.

Review of the facility policy and procedure for "Initiation of Transmission Based Precautions" evidenced the following, in part: "...Procedure: Rationale for Transmission Based Precautions in Hospitals: a. Transmission of infection within hospital requires three elements: 1) Source - Human a) patients, b) Personnel, c) Visitors, d) Persons with acute disease, e) Persons in the incubation period of a disease, f) persons colonized by an infectious agent but have no apparent disease, g) Persons who are chronic carriers of an infectious agent. 2) Patients endogenous floras. 3) Inanimate environmental objects that have become contaminated, including equipment and medications...c. ...1) Contact Transmission- the most important and frequent mode of transmission of infection: a) Direct Contact- involves direct body surface-to-body surface contact and physical transfer of microorganisms between a susceptible host and an infected or colonized person. b)Indirect contact- involves a susceptible host with a contaminated intermediate object, usually inanimate, such as contaminated instruments, needles, dressings, or contaminated hands that are not washed and gloves that are not changed between patients."

The hospital policy "Infection Control Guidelines for Dialysis" was reviewed and evidenced: "...4. Approach all patients, body fluids, dialyzers, supplies and equipment used for patient's treatment as if they are infectious/contaminated....DISINFECTION: 1. General cleaning and disinfection of surfaces and non-disposable equipment will be done using a hospital approved disinfectant compatible with surfaces/equipment...5. After each dialysis treatment is completed: ...b. Clean and disinfect ancillary equipment (vascular access clamps, hemostats ect.) Apply a hospital approved disinfectant to wet the surfaces, and allow to air dry per manufacturer's guidelines. c. Clean and disinfect the dialysis station or treatment area (chairs, tables, machines ect.) Apply sufficient a hospital approved disinfectant per manufacturers guidelines (sic)..."

On 4/25/18 at 12:30 p.m. the surveyor interviewed Staff Member # 20 (Infection Control Nurse) regarding the hospital approved cleaner for the dialysis machines. Staff Member #20 stated, "...they (staff) have been instructed to use bleach. I've went over with them how long they are to have the surface wet...if there is c-diff they are to clean with the purple top cloths first and wait two minutes, then clean with the bleach cloths and dwell four minutes...each canister kills certain types of bacteria and viruses..."

At 1:45 p.m. on 4/26/18, the Dialysis Director, Staff Member #18 was interviewed, Staff Member #18 stated, "All machines are treated the same whether they are isolation or not. We use the hospital approved wipes. We use the purple top and the yellow top...we use bleach, whichever color top that is...I do not know what is in either one (type of disinfectant) (asked Staff Member # 19 to get canisters of the cleansers- Staff member #19 returned with the purple and yellow top canisters)...the yellow is the bleach. They are to use the purple top and follow with the bleach...I do not know the wait time between..."

On 4/26/18 at 8:45 a.m., the surveyor discussed the observations with Administrative Staff Members #1 (CEO), #2 (CCO), #5, #11 (Quality), and #19 (Corporate Representative).

On 4/27/18 at 12:00 p.m. the survey team discussed the observations and findings with the Administrative Staff #1, #2, #5, #11, and #19.

2. Patients #2 and #12 did not have their Hepatitis B status known prior to the first dialysis treatment/admission at the facility and Patient #12 was not offered the Hepatitis B Vaccine.

Review of the clinical record for Patient #2 revealed the patient was admitted 4/9/18 with diagnoses that included, but were not limited to : C-difficile infection, respiratory distress, multi organ system failure and renal failure. Patient #2 was ordered, and received the first dialysis treatment at the facility on 4/11/18 at 1:40 p.m. Further review of the clinical record with the assistance of Staff Member #11 (Quality Manager) on 4/25/18 did not evidence any lab studies prior to Patient #2's admission to determine the patient's Hepatitis B status. The clinical record contained evidence that lab testing had been collected after admission, however no results were available prior to admission/first treatment.

Patient #12 was admitted 4/10/18 with diagnoses that included, but were not limited to: respiratory failure, chronic kidney disease, hypertension and congestive heart failure. Review of the clinical record with the assistance of Staff Member #11 on 4/25/18 revealed Patient #12 received dialysis treatment on 4/11/18, however the lab results for the Patient's Hepatitis B status were documented as "pending" at the time of the treatment (1:15 p.m.). Patient #12 had received dialysis treatment at another facility prior to transfer to this hospital, however the lab studies in the transfer documented listed "Hepatitis B- latest result not flagged". The surveyor and Staff Member #12 were not able to locate in the clinical record any results prior to the first treatment at the facility.

A 'lab document" contained in the clinical record for Hepatitis B Surface AB (antibody) was evidenced, dated as collected 4/12/18 and reported 4/13/18. The result indicated "non Reactive- inconsistent with immunity, less than 10 mIU/ml (less than ten milli International Units per milliliter). This result according to the CDC (Centers for Disease Control) indicated the patient had no immunity and was susceptible to the Hepatitis B Virus. Also the CDC recommends that in order to prevent the transmission of Hepatitis B among ESRD (end stage renal disease- hemodialysis patients), all new patients should be tested and their hepatitis serological status known prior to the first treatment. Susceptible patients should begin receipt of hepatitis B vaccine immediately. (Centers for Disease Control www.cdc.gov).

According to the facility policy and procedure "Hepatitis B Vaccination" the following was evidenced, in part: "...1. It is the policy of Vibra Healthcare that all dialysis patients will be monitored for Hepatitis B...if the results fall below 10 (ten) milli-international units per milliliter of blood the patient is identified as high risk for developing hepatitis and will be offered the Hepatitis B vaccination series...8. The patient may refuse the vaccine...but they must sign the Hepatitis B Consent/Declination Form..."

The facility policy "Dialysis Routine Testing" documented, "The HBV (hepatitis B virus) Serological status of all patients should be known prior to admission..."

In an interview with Staff Member #2 (CCO) on 4/25/18 at 5:00 p.m., he/she stated, "We do not give the hepatitis vaccines to the dialysis patients. We've never done that. We monitor their serology, but do not give any vaccines."

On 4/26/18 at 8:45 a.m., the surveyor discussed the observations with Administrative Staff Members #1 (CEO), #2 (CCO), #5, #11 (Quality), and #19 (Corporate Representative).

On 4/27/18 at 12:00 p.m. the survey team discussed the observations and findings with the Administrative Staff #1, #2, #5, #11, and #19.


40084


3. On April 25, 2018 at 1:37 p.m., Staff Member #2 escorted surveyors to the dialysis suite. Upon observation in the suite, surveyors noticed several one (1) gallon containers of bath solution sitting on-top of a central supply cart beside other supplies. The containers were partially empty and appeared to have initials on the side. The Technical Director of Dialysis, Staff Member #18, was present in the dialysis suite at the time and was interviewed by the surveyors. Staff Member #18 advised the bath solution observed by surveyors was not dedicated to one single patient even if that patient was on isolation precautions. Staff Member #18 explained as regular practice, solutions are taken by dialysis nurses into the patients' room, removed from the room after treatment and may enter another patient room based on dialysis needs of the facility. Staff Member #18 identified one bath solution container presently sitting atop the central supply cart as one that entered an isolation precaution room that day. Staff Member #18 explained the container was removed from the room and placed back onto the central supply cart with other supplies and solution. He/she further advised nurses are supposed to clean the outside of the containers prior to exiting the patient room and any solution remaining at the end of the workday is to be discarded.


34756


4. On 4/24/18 at approximately 10:45 a.m., during a tour of the facility, the surveyors, accompanied by
Staff Member (SM) #11, entered the room of Patient #1, who was being dialyzed by SM #9, a contracted hemodialysis registered nurse (RN). Patient #1 was on contact precautions. The surveyors observed a tote bag made of quilted looking material sitting on the hemodialysis (HD) machine. The bag had a jacket folded up inside with the zipper open. The surveyors inquired as to the contents of the tote, and at 10:50 a.m., SM #9 stated "that's extra supplies". The surveyors observed extra supplies, including an unopened dialyzer and syringes in the bag, along with the coat. When asked about the coat, SM #9 stated "That's my personal coat. I get cold in here, and I need my coat". SM #9 attempted to correct SM #11, at which point SM #9 became argumentative and said "I'm going to take my coat, I'll be going from room to room anyway...".

Between approximately 12:00 p.m. and 12:30 p.m., the surveyor observed SM #9 discontinue dialysis for
Patient #1, and made the following observations related to infection control: SM #9 removed the hemodialysis lines from the machine, placed them into the biohazard trash receptacle with approximately 500 ml (milliliters) of saline left in the bag. SM #9 cleaned the front of the HD machine, without cleaning/disinfecting the acid or bicarbonate knobs or lines, intravenous (IV) pole, hemostats, and other supplies hanging from the IV pole. SM #9 then wiped the water and drain lines lying on the floor between the HD machine and the bathroom sink/floor drain, laid the lines back onto the floor, and stepped on the lines while moving around in the room. SM #9 removed the prime waste receptacle and emptied it into the (clean) sink used by staff for handwashing; the prime receptacle was rinsed out with water, but disinfectant wipes were not used. SM #9 removed gloves, reached into the glove box, and donned clean gloves, without washing or sanitizing his/her hands, then removed Patient #1's central venous catheter (CVC) dressing.
SM #9 then removed gloves, washed hands, applied a new CVC dressing, and blocked the catheters with anticoagulant. SM #9 removed personal protective equipment (PPE), exited the room, returned to the room, donned an isolation gown and gloves, without tying the gown. SM #9 pushed the HD machine against the privacy curtain at the bedside, tied the gown, turned off the portable HD machine after the disinfect was completed, walked to the clean area of the room where isolation PPE was stored in a cabinet, got wipes from the purple tub, unplugged the machine, and wiped the electric cord, put the cord onto the back of the machine, went to the bathroom, disconnected the water supply at the sink, put a glove over the end of the tube, and, with water dripping onto the floor, coiled up the water and drain lines, and clamped them onto the back of the HD machine. The cord and lines were touching the floor. SM #9 pushed the machine out of the room into the hallway. Before leaving the room, the surveyor asked SM #9 what Patient #1's post dialysis weight was; SM #9 went to the bed, pushed a button on the side of the bed rail, and said "158." The head and foot of Patient #1's bed were elevated; SM #9 obtained weight with the bed in that position, which alters the accuracy of the weight.

At 9:05 a.m. on 4/25/18 while making observations on the second (2nd) floor, SM #5 was interviewed about the proper method for using bed scales, SM #5 stated "the beds are zeroed with the patient in the bed on admission; beds have to be flat to get an accurate weight".

5. Between 9:10 a.m. and 9:25 a.m. on 4/25/28, while accompanied by SM #5, the surveyor observed housekeeping staff, SM #12, in the process of cleaning room 221, an isolation room of a patient on contact precautions "strict handwashing". SM #12 mopped over to the door, removed PPE gown, picked up a bag of trash from inside the room, walked outside the door wearing gloves he/she used while cleaning, and placed the bag in a large trash bin outside the door. SM #12 removed gloves but did not was his/her hands, got trash bags, walked into room 222, opened the bathroom door, went back to the housekeeping cart, touched items on the cart, then walked down the hall to the soiled utility room, opened a locked door with a key pad, and came out after a few minutes. SM #12 went back into room 221, washed hands, donned new gloves and gown, put the trash bags down, wiped something up off the floor with a cleaning cloth, swept debris from inside the room out past the door into the hallway, pushed the debris into a dust pan, and disposed of it in the trash on the housekeeping cart. SM #12 removed the mop head and placed it in a bag on the housekeeping cart, removed PPE, and without washing his/her hands, pushed the housekeeping cart to room 223, then pushed the trash bin outside of room 223. He/she entered room 223 and began mopping; he/she did not wash hands before or after entering patient room 223.

The patient in room 221 was on isolation precautions for Carbapenem-resistant Enterobacteriaceae(CRE), Acinetobacter, Methacillin Resistant Staph Aureaus (MRSA), and CRE-KP in urine.

SM #20, the RN infection preventionist was interviewed on 4/26/18 related to infection control training for housekeeping staff; he/she stated "Housekeeping is not included in general orientation, there are monthly meetings, when I see them not in compliance I speak to them, and I speak to their manager. I guess their department has some training. Not everybody goes through general orientation. Housekeeping doesn't attend now. Their manager provides inservices, or the company provides orientation and training. I do N95 fitting. The manager teaches staff about handwashing. The employee may be here working before an orientation is done/complete ".

The facility's policy and procedure entitled "Infection Prevention and Control Orientation" was reviewed, and stated in part : "...7. Each Department Manager will be responsible for orientation of new employees to Infection Control standards specific to their department...".

SM #24, contracted housekeeping manager, was interviewed on 4/27/18 at 11:30 a.m., and stated "Housekeepers are trained before they start. I haven't utilized the facility orientation document. I'm hands on with them training-I work with them for a week. I follow up by observing them, employee rounding to ensure they are performing duties correctly, as taught. I will make a plan of correction for this employee".

On 4/25/18 at 11:45 a.m. the surveyor, accompanied by SM #5, observed SM #13 discontinuing dialysis for
Patient #14, who was on contact precautions. SM #5 observed that Patient #13's oxygen saturation was reading low, pulled back covers, and looked at the pulse oximeter on the patient's finger. SM #5 then took off one glove and reached around the PPE gown to get a small notebook from his/her pocket, touching scrub pants with the gloved hand. SM #5 removed the other glove and gown to leave the room, but respiratory therapy stopped at the door, and brought another pulse oximeter. Without washing or sanitizing hands, SM #5 got another gown from the isolation cart and put it on, sanitized hands, and donned gloves.

At 11:50 a.m. after reinfusing Patient #14's blood and taking down the lines, SM #13 wiped off the computer screen with the yellow (bleach) wipes, emptied prime receptacle container into the handwashing sink, wiped it out with the bleach wipes, then placed it back on the machine. SM #13 wiped off the side of the machine with the basket containing the blood pressure (BP) cuff, wiped off the BP tubing, and placed it into the basket. SM #13 then wiped three (3) sides of the plastic bin which contained extra supplies, and wiped off the top surface of the portable reverse osmosis (RO). SM #13 disconnected the water supply line and the drain lines in the bathroom, coiled them up, clamped them onto the back of the machine, and wiped some, but not all of the surface of the lines. SM #13 changed Patient #14's CVC dressing at 12:20 p.m., washed his/her hands, donned new gloves, lifted PPE gown up, reached into uniform pocket for a label, which he/she wrote on and placed on dressing. SM #13 opened isolation cart and obtained supplies while wearing the contaminated gloves. Patient #14's weight was obtained while the bed was not in the flat position.

SM #13 removed PPE, sanitized hands, and rolled the machine out of the room and into the dialysis suite.
After taking the HD machine into the dialysis suite, the surveyor asked SM #13 if the machine was ready for use for the next patient. SM #13 stated "Yes, I cleaned the machine". The surveyor described the observation that only one side of the machine and the tops of the portable RO were wiped off prior to taking the machine into the dialysis suite with clean equipment; that the dialysate jugs sitting on the machine, as well as all other areas of the machine, had not been cleaned/disinfected prior to leaving the patient room. SM #13 stated "I cleaned the machine, but we have plenty of wipes, I will clean it again".

SM #18, the contracted dialysis administrative technician, , was in the dialysis suite, and was interviewed and was asked the expectation for cleaning and disinfection of the HD machine after use in a patient room, prior to returning to the dialysis suite, and as to clean/dirty sinks; he/she stated "We treat all machines as if they are in isolation. We follow the hospital policy and procedure using approved wipes. We thoroughly clean every nook and cranny, no matter where the patient is dialyzed, in the room or the suite. When dialyzing in the rooms, there's no designated clean/dirty area, but the bathroom is considered the dirty area. That is where the prime bucket should be emptied. In the clean area everything should be clean, and the dirty area, everything should be considered dirty".

At approximately 12:45 p.m. on 4/25/18, SM # 20 was interviewed related to infection control practices and cleaning of hemodialysis equipment. SM #20 stated "The director of quality and the unit secretaries help me with observations. I get 100-200 observations a month, our goal is 95%. Dialysis staff are like any other clinical staff. If they are dialyzing a patient on precautions, I look to see if they are running a treatment on a patient. They are to refrain from using cell phones in the room, they don't take personal items into the room. They have all been instructed how to clean the machines. They are to use purple wipes first with a dwell time of 2 minutes, then bleach wipes with a dwell time of four (4) minutes".

During an interview with SM #18 on 4/26/18 between 1:45 p.m. and 2:45 p.m., the contracted dialysis administrative technician, stated the following related to cleaning of HD machines "All machines are treated the same. We use hospital approved wipes for cleaning and disinfection of the machines. We use the purple tub-(product name)-I can't recall whether bleach is the yellow or purple tub. We don't use both".

6. Eleven (11) personnel records were reviewed. Seven (7) of 11 records lacked proof that staff had either been offered a Tetanus, diphtheria, acellular peruses (Tdap) vaccination, or had proof of receipt of the vaccine; six (6) staff records lacked either evidence of immunity to varicella, or vaccination with the varicella vaccine; four (4) staff records lacked either evidence of immunity to measles, mumps, rubella (MMR), or a MMR vaccination; one (1) record lacked documentation that a hepatitis B series had been offered, declined, or that the staff member had immunity to hepatitis B; and two (2) records lacked documentation of a current flu vaccination or a signed declination of the vaccine.

Staff Member (SM) #20, was interviewed on 4/26/18 at 12:30 p.m. related to required vaccinations for facility staff, and stated "(facility name) does not have a policy that stated employees have to have either a varicella titer or vaccine, we will have to change the policy. Yes, I know what the requirements of the regulation are. Schools require varicella vaccine for school admission, so everyone would have it".

On 4/27/at 12:04 p.m. SM #19 provided the surveyors with a policy entitled "Disease Preventable Vaccines", which stated in part "...The following vaccines are required for all employees, contracted service providers, licensed independent practitioners (LIP), and credentialed ancillary staff, unless contraindicated. Proof of immunity (serological laboratory documentation of immunity or vaccine administration records) is required. For those persons without documentation of vaccine administration, serological laboratory testing will be required. If the healthcare worker of Licensed Independent Practitioner is found to be non-immune, appropriate vaccines will be administered, unless contraindicated. The following vaccines will be required:
* Hepatitis B (for healthcare workers who have potential for occupational exposure to blood and/or body fluids
* Influenza (seasonal)
* Measles, Mumps, Rubella (MMR)
* Varicella
* Tetanus, Diptheria {sic}, Pertussis (TDaP) {sic}...".
SM #19 stated "This is our policy, but we are not following it".

Observations and concerns were discussed with management as noted above, and again on 4/27/18 between
12:00 p.m. and 12:30 p.m. at the exit conference.


21876

7. An observation was conducted in the Physical Therapy room on April 24, 2018 from 10:44 a.m. through 11:01 a.m., with Staff Member #5 during the tour of the facility. Staff Member #5 confirmed the facility's patients did receive services in the Physical Therapy room. Staff Member #5 reported the Physical Therapy services were provided under contract. Observations revealed the inversion table's pad had three (3) tears ranging from one-fourth (1/4) to three-quarters (3/4) of an inch on the right side. The pad also had two (2) tears on the left side approximately one-half (1/2) inches each. Staff Member #5 verified the table's pad was not intact and could not be disinfected between patients. The observation revealed a tri-fold pad stored on the floor between the stationary mat-table and the wall. The mat-table had a layer of whitish-gray substance on the surface and a note, which indicated the mat-table, had been cleaned. Staff Member #5 identified the whitish-gray substance as "dust." Staff Member #5 verified the mat-table was not clean and the tri-fold pad should not have been stored on the floor. The surveyor requested the facility's policy related to cleaning items between patients.