Volume 2024 | No. 2
SURVEYOR
RENAL DIALYSIS
SECTION 7: RISK MANAGEMENT: INFECTION AND SAFETY CONTROL RD7-A Overview of the requirement: Written policies and procedures govern an infection prevention and control program designed to protect patients and personnel from communicable disease and infection.
RD7-B Overview of the requirement:
Policies and procedures follow CDC recommendation and OSHA mandates for Hepatitus B vaccination of patients and staff. Compliance is evaluated through review of policy and procedure, other records, and response to interviews. Surveyor findings came from document review and most deficiencies were a result of noncompliance with the organization’s policy for testing and vaccination.
Comment on deficiencies:
Comment on deficiencies:
Compliance is evaluated based on review of policies and procedures, direct observation, response to interviews, and review of personnel files. Most citations noted a failure to distinguish between clean and dirty areas when managing supplies and equipment. Improper use of PPE (especially gloves) also was frequently observed.
Frequency of citation:
32%
Examples of surveyor findings:
n During review of the facilities hepatitis vaccination tracker, it was noted that an admitted patient signed a consent to receive the Hepatitis B vaccine two days after admission and was scheduled to receive the first vaccine four days later but it had not been administered at the time of survey (14 days after consent was received). n The organization is not following its patient hepatitis testing and vaccination policy. Six of ten patient records reviewed did not include evidence that the vaccine series had been offered, nor was a document declining the vaccination present. n Not all personnel files included evidence of hepatitis B antigen titer being drawn, vaccine administered, or vaccine declined. n Identify the HBV serological status of all patients before admission to hemodialysis. n Routinely test patients for hepatitis B vaccine and should seroconversion occur, investigate possible sources of infection against unit practices and procedures. n Segregate HBsAg positive patients from others for treatment.
Frequency of citation:
62%
Examples of surveyor findings:
n A staff member was observed placing a used face shield on top of the clean supplies and medication preparation counter. n Staff stores clean supplies behind the treatment station while a patient is on dialysis. These supplies were not discarded at the end of treatment. n Staff members were observed wiping down each dialysis machine, but did not disinfect the RO machine and the computer within the station. n Clean and dirty areas are not clearly separated. Used supplies and equipment are handled and clean supplies are stored in the same area. The PD training room had a centrifuge used for spinning lab tubes sitting beside a clean sink, with no barrier separating the clean/dirty area. Clean supplies were stored above and below the centrifuge. The emergency eye wash station was installed onto the dirty sink. n Staff members placed used CVC caps, gauze, and alcohol pads on the barrier pad where clean gauze and saline syringes were located. n The physician assessing patient heart and lung sounds at the initiation of treatment did not don gloves. n Staff on the treatment floor were observed donning gloves that they were carrying in their pockets. n Evaluate clean and dirty storage locations. Ensure adequate separation between the two. n Educate staff on processes to avoid cross contamination before, during, and after procedures. n Disinfect equipment between patients. n Reeducate staff on required hand hygiene and gloving protocols.
Tips for compliance:
Tips for compliance:
achc.org | (855) 937-2242 | 13
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