Inadequate infection control in the Dialysis Unit of the LBJ Hospital is an outstanding deficiency that the Centers for Medicaid and Medicare Services found in its re visit survey of LBJ hospital last year.
The LBJ was written up for the same deficiency in the 2014 survey.
The CMS report of their follow up visit documents examples where the Dialysis Unit staff did not adhere to basic infection control procedures which are standard for any health care facility.
CMS said based on observation, patient and staff interviews and review of medical records, facility logs, policy and procedures and quality assessment and performance improvement documentation, the facility did not ensure that Dialysis staff wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station.
Neither did they wash hands or changed gloves between each patient or station, did not wear gowns, face shields, eye wear or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or splattering of blood might occur.
The CMS found that staff did not show evidence of vaccination of all susceptible patients and staff members against hepatitis B, did not ensure that staff member caring for hepatitis positive patients should not care for Hepatitis susceptible patients at the same time, including during the period when dialysis is terminated on one patient and initiated on another.
The cumulative effect of these systemic practices prevented the facility from providing statutorily required services under infection control.
A basic condition that CMS cited was that staff did not wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station.
CMS said staff must remove gloves and wash hands between each patient or station but this standard is not met.
The survey team found on December 2 last year, a certified clinical hemodialysis technician was inside the isolation room without gloves on both hands attending to a patient.
The staffer was seen touching the dialysis machine and documenting readings on the treatment record kept in a plastic binder she held.
Thereafter the staffer left the room, walking to the nursing station and placed the binder on the top of the counter.
Shortly after , the same staff member walked back into the isolation room, put on gloves on both hands, folded a white sheet draped over the other dialysis chair in the room which was vacant and laid it on the seat.
While inside the room the staffer removed her gown and gloves, disposed them in the trash container immediately outside the isolation room door, returned to the room, washed her hands in the sink adjacent to the patient’s chair and then left the room.
According to CMS, a review of the medical record revealed that the patient in the isolation room was admitted with diagnoses of end stage kidney disease requiring dialysis treatment, and hepatitis B infection, the primary reasons for his use of the isolation room.
The CMS documents an interview the day after. A nursing administrative staff said that facility policy required that all staff caring for patients in the isolation room should wear protective equipment including a gown, gloves and a face shield.
However this standard is not met.
The federal agency notified LBJ last month that the Dialysis Unit may lose its certification for Medicare coverage October 31 because of the deficiencies.
LBJ has submitted a plan of correction to CMS on how to address the deficiencies cited, and LBJ is now awaiting a decision on whether the plan is acceptable and ward off termination of its Medicare coverage.
