Volume 2025 | No. 2
SURVEYOR
RENAL DIALYSIS AMBULATORY SURGERY CENTER
■ A common supply cart stocked with gallon jugs of bicarb solutions was positioned within the treatment station where a patient was actively dialyzing. ■ One staff member did not remove her gloves when leaving the patient’s station, nor did she wash her hands before obtaining a clean bleach rag from the clean bleach container. One staff member did not don gloves when moving patients from their wheelchairs to their dialysis chairs or when touching their belongings to prepare them for dialysis. ■ During initiation of treatment, a staff member was observed placing a used vacutainer and a tube of blood alongside clean supplies designated for cannulating the access and normal saline infusion. ■ While initiating treatment with a CVC, one staff member placed used syringes on the clean drape where alcohol preps were in place to be used to scrub the hub. Another staff member, initiating treatment using an AVF, placed a blood filled syringe on a clean pad with other clean syringes and alcohol pads. The staff member continued to use the supplies from the clean pad that became soiled with blood leakage from the AVF site while initiating treatment. ■ A staff member’s cell phone was placed on a counter designated for clean supplies.
RD7-C Frequency of the citation: 26%
Overview of the requirement: Based on the services provided, the organization provides infection control education and training to its employees, contracted providers, patients, and their family members. Clinical staff demonstrate competence and compliance with infection control principles. Comment on deficiencies: Written policies and procedures, personnel files, medical records, direct observation and response to interview are used to assess compliance with the standard. Most noncompliance was failure to follow the organization’s policies for preventing catheter-related infection, noted by direct observation. Examples of ACHC Surveyor findings: ■ The policy, “Dialysis Catheter Care,” requires visual inspection and a dressing change with each treatment. Two of six patient records reviewed did not have evidence of catheter care on one treatment date. Another record, for an assisted treatment in the patient’s home, included no evidence that the catheter site was visually inspected and a dressing change completed. ■ Three of six personnel records reviewed did not include evidence of infection control training. ■ A staff member initiating care of a CVC did not remove his gloves, perform hand hygiene, and don clean gloves to minimize cross contamination at three risk points: after removing the old CVC dressing, prior to placing the new CVC dressing, and prior to initiation of treatment. ■ During observation of care, a staff member opened up all the supplies used to initiate treatment for a patient with a CVC. The caps were removed from the heparin filled syringes, the normal saline filled syringes, and the packaging was removed from two 10 cc syringes. The staff member then proceeded to move over and care for another patient for more than 15 minutes, leaving all previously opened supplies exposed and unprotected from potential contamination. As the staff member began the process of removing the CVC dressing to initiate a change, they opened a sterile swab taking it out of the package and placing it on the pad with the other supplies. Once the dressing was completely removed, the staff member then picked up the swab from the pad and proceeded to clean the skin around the outer area of the CVC site with the contaminated swab.
Compliance tips for:
The intent of this standard is to highlight the details critical to effective infection prevention and control. Policies and procedures are expected to be developed and rigorously implemented. ■ Evaluate clean and dirty storage locations and ensure adequate separation between them. ■ Disinfect equipment between patients.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
■ Hold regular infection prevention training.
Nerd Trailblazers (prepare the path for others)
ٝ Segment training for avoiding cross-contamination into before, during, and after treatment modules. ٝ Engage staff with “spot-the-error” scenarios.
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