032536 Winslow Dialysis Center (Fmc)

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 50568 Based on document review, observation, and staff interview, the Department determined that the facility failed to ensure that direct care staff did not have artificial nails while providing patient care. Failure to follow established standard and infection control precautions poses an increased risk of infections for immunocompromised patients through contact transmission and cross contamination. Findings include: The CDC “ Morbidity and Mortality Weekly Report”, October 25, 2002 / Vol. 51 / No. RR-16, Guideline for Hand Hygiene in Health Care Settings Recommendations:” ; revealed: “;...HCWs who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than are those who have natural nails, both before and after handwashing...Personnel wearing artificial nails have also been epidemiologically implicated in several other outbreaks of infection caused by gram-negative bacilli and yeast...These recommendations are designed to improve hand hygiene practices of HCWs and to reduce transmission of pathogenic microorganisms to patients and personnel in healthcare settings...Do not wear artificial fingernails or extenders when having direct contact with patients at high risk....” Observation on June 25, 2024 revealed Employee #15, #16, #17 providing patient care services in the treatment area for patients on dialysis while wearing artificial nails. Visual inspection during seperate interviews conducted by the suveyor confirmed the presence of artifical nails on Employees #15, #16, #17. In separate interviews conducted on June 25, 2024, Employees #15, #16, #17 confirmed that they are wearing artificial nails while providing patient care, despite the facility policy prohibiting artificial nails while providing direct patient care. Employees #15, #16, #17 also confirmed that they had received training regarding infection control and artificial nails. In a separate interview conducted on June 25, 2024 Employee #1 confirmed that staff were trained annually on infection control practices. Employee #1 confirmed that staff had been informed they are not permitted to wear artificial nails.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 50568 Based on document review, observation, and staff interview, the Department determined that the facility failed to ensure medications were locked when not in use at the medication preparation station. Failure to secure medications when not in use may result in unauthorized access to medication not prescribed to an individual and the potential for tampering or other compromise to the integrity of medications administered. Findings include: Facility policy titled, “Medication Preparation and Administration” states, “Purpose: To administer medications with the goals of staff and patient safety, optimal therapeutic response, and infection control ... All medications will be kept in a locked cabinet except when in use ...” A tour of the facility was conducted on June 24, 2024 revealed unsecured medications within patient care areas. In the area designated as the treatment floor, 2 (two) nurses station were noted (North and South). In the South nurses station, the following are located; 2 (two) metal filing cabinets with locking medications, 1 (one) labelled “PO” and 1 (one) labelled “IV”. Upon further inspection, both medication metal drawers were unlocked and contained both oral and intravenous medications. During an interview conducted on June 25, 2024, Employee #1 confirmed that the facility failed to ensure that medications were secured when not in use, and this practice did not comply with following policy.”

“PE-FIRE SAFETY-LIFE SAFETY CODE CFR(s): 494.60(e)(1) (1) Except as provided in paragraph (d)(2) of this section, dialysis facilities that do not provide one or more exits to the outside at grade level from the patient treatment area level must comply with provisions of the Life Safety Code (NFPA 101 and its Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4) applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. This Standard is not met as evidenced by: 50568 Based on document request and staff interview, the Department determined that the facility failed to ensure a current fire inspection report was maintained. Failure to ensure a current fire inspection report is maintained poses a potential patient safety risk in the event of a fire due to hazards not identified and/or corrected. Findings include: A copy of a current fire inspection report was requested during survey enterance on June 24, 2024. The provided local fire authority documentation from the facility was an inspection report dated 09/14/2023, that reads, “ ...please have sprinkler head escutcheon replaced by Fire protection Co. and the three exit signs repaired or replaced. We will follow up in 30 days ...”. No further documentation by the facility was provided to ensure the loca fire authority had revisited and cleared the facility. On June 25, 2024 the on-site surveyor contacted the local fire authority (City of Winslow) to confirm if the facility had a follow up survey. The representative of the fire authority was unable to confirm that the facility was up to date. End Stage Renal Disease Centers (ESRD) are considered high risk and are required to be inspected annually. Employee #1 confirmed during an interview conducted on June 25, 2024, that the facility did not have a current fire inspection report.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 50568 Based on review of policies and procedures, medical records and interview with staff, it was determined the facility failed to ensure that CIPA ws completed in a timely manner to reflect review of unstable patients every 30 (thirty) days. The failure to identify, assess and update the CIPA can pose a serious risk to the patient, and may lead to an increase in hospitalization, readmissions, and death. Findings include: Facility policy titled “Arizona State Specific - Care Planning Frequencies” states that, “ ... the patient whose medical condition is unstable must have the Assessment Update/Plan of Care Update of the Plan of Care will be reviewed and updated every thirty (30) days until stable ...” Patient #14 was designated as unstable in the 12/2024 Plan of Care. The next Plan of Care provided was dated 02/2024. Monthly Progress notes by the Social Worker dated 04/26/2024 states, “ ... unstable ...” demonstrating that there was no change in status. When requested, the facility did not provide any further Plans of Care for the months of 01/2024, 03/2024, 04/2024, nor 05/2024 despite the patient’s unstable designation. Patient #7 was designated to be unstable in the 1/2024 Plan of Care. When requested, the facility did not provide any further Plans of Care beyond that of 01/2024 or documentation of the patient returning to a stable status. Patient #8 was designated to be unstable in the 04/2024. When requested, the facility did not provide any further Plans of Care beyond that of 04/2024 or documentation of the patient returnnig to a stable status. During an interview conducted on June 25, 2024, Employee #1 confirmed that further documentation could not be provided for the missing Plans of Care.”