032537 Estrella Dialysis Center (Fmc)

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 40084 Based on five (5) infection control observations, interview, and document review, it was determined facility staff failed to disinfect items taken into the dialysis station, namely a stethoscope, before being removed from the dialysis station. The findings include: On February 27, 2024, while conducting observations on the treatment floor, surveyors noted the following: At 9:22 a.m., Staff Member #5 used a stethoscope with a leopard print cloth cover on a patient at dialysis station #2. Staff Member #5 used the stethoscope on the patient, placed the stethoscope around their neck, and then exited the dialysis station. Staff Member #5 did not disinfect the stethoscope after use on the patient and additionally the item could not be properly cleaned based on the cloth cover. At 10:21 a.m., Staff Member #5 performed the same action as described above at station #2 and at 10:24 a.m. at station #22. At 10:06 a.m., Staff Member #8 used a stethoscope on a patient at dialysis station #5. Staff Member #8 used the stethoscope on the patient, placed the stethoscope around their neck, and then exited the dialysis station. Staff Member #8 did not disinfect the stethoscope after use on the patient. At 10:49 a.m., Staff Member #8 performed the same action as described above at dialysis station #8. During an interview at 1:35 p.m. on February 27, 2024, Staff Member #1 and Staff Member #2 advised they were aware of the staff member with the stethoscope with a cloth cover that and that cleaning stethoscopes after use on patients has been challenging with new nurses. A review of the facility policy titled “Cleaning and Disinfecting the Dialysis Station” (effective date 09/05/23) states in part: “After use, any non-disposable equipment and supplies brought into the dialysis station (ex. Stethoscope) must be disinfected with 1:1,000 bleach of EPA registered disinfectant before being removed from the dialysis station.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 40084 Based on three (3) infection control observations and interview, it was determined the facility failed to clearly designate an area as clean or dirty. Specifically, the facility staff used a sink with clean items, namely an area for storage of pHoenix meters and calibration fluids, as a dirty sink to drain dirty prime buckets and bags of normal saline used during dialysis treatment. The findings include: The surveyor conducted an observation on February 27, 2024 at 8:36 a.m. of Staff Member #14 discontinuing dialysis for a patient at dialysis station #4. The surveyor observed the staff member drain the dirty prime bucket and a bag of normal saline used during dialysis treatment into a sink with designated clean items (pHoenix meter and calibration fluids). The sink did not have signage indicating “clean” or “dirty.” The surveyor observed Staff Member #14 perform the same action at 10:44 a.m. during a discontinuation of dialysis for a patient at station #5. The surveyor conducted an observation on February 27, 2024 at 10:59 a.m. of Staff Member #14 placing dirty clamps used on a patient during dialysis into a bucket of bleach at the same sink as described above. The surveyor observed a second sink at the other side of the treatment floor labeled as a dirty sink. Additionally, the surveyor observed staff members appropriately using that sink for draining prime buckets, normal saline bags, and soaking dirty clamps used during dialysis into a beach solution. The surveyor conducted an interview with Staff Member #1 on February 28, 2024 at 1:35 p.m. Staff Member #1 advised that one of the clinic sinks was not working properly and this may be the reason staff were using an alternate sink. The facility policies provided to surveyors while onsite did not cover the use or designation of clean/dirty sinks.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 40084 Based on interview and document review, it was determined the facility staff failed to monitor patients during dialysis per facility policy for three (3) out of twelve (12) patients sampled (Patients #2, 6, 9). Specifically, staff failed to notify the nurse of blood pressure readings that exceeded facility parameters and failed to obtain a blood pressure and pulse reading at least every forty-five (45) minutes. The findings include: The surveyor conducted a review of two (2) weeks of flow sheets for Patients #1-12 on February 28, 2024. That review revealed the following: For Patient #2: During dialysis treatment on February 13, 2024, the patient’s blood pressure exceeded facility parameters as indicated by policy and the flowsheet did not evidence notification to the nurse. Additionally, the flowsheet revealed that staff did not obtain a blood pressure and pulse rate for fifty-one (51) minutes during treatment. During dialysis treatment on February 17, 2024, the patient’s blood pressure exceeded facility parameters as indicated by policy and the flowsheet did not evidence notification to the nurse. During dialysis treatment on February 24, 2024, the patient’s blood pressure exceeded facility parameters as indicated by policy and the flowsheet did not evidence notification to the nurse. For Patient #6: During dialysis treatment on February 17, 2024, the flowsheet revealed that staff did not obtain a blood pressure and pulse rate for fifty-seven (57) minutes during treatment. For Patient #9: During dialysis treatment on February 15, 2024, the flowsheet revealed that staff did not obtain a blood pressure and pulse rate for seventy-four (74) minutes during treatment. During dialysis treatment on February 22, 2024, the flowsheet revealed that staff did not obtain a blood pressure and pulse rate for seventy-one (71) minutes during treatment. On February 28, 2025 at 1:35 p.m., the surveyor conducted an interview with Staff Member #1 and Staff Member #2. Staff Member #1 advised that patients should have their vitals checked every thirty (30) minutes during dialysis and any abnormal findings during dialysis require documentation in the medical record and notification to the nurse. A review of the facility policy titled “Patient Assessment and Monitoring” states in part: “Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations.” “Report to the nurse: Systolic blood pressures greater than 180 mm/Hg Diastolic blood pressure greater than 100 mm/Hg””