032580 Palm Valley Dialysis (Fmc)

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 45999 Based on document review, observation, and interview, it was determined that the facility failed to ensure: 1. (2) of (12) dialysis chairs did not have tape residue on the tray tables which poses a potential infection control risk from inadequately cleaned and disinfected chairs; 2. Dialysis stations cleaned areas including the machine, attachments such as an IV pole, BP cuff, individual television, and arm of the television. Clean keyboards with a soft cloth with 1:100 bleach solution. Findings include: 1.& 2. The facility policy titled “Physical Environment” requires: “...The space for treating each patient will be sufficient to provide needed care and services, prevent cross-contamination....” The facility policy titled “Infection Control for Dialysis Facilities” requires: “...Disinfection...Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials...Prior to routine disinfection, remove all visible blood...For visible blood or gross blood spills, a 1:10 (one to ten) bleach solution must be utilized...After all visible blood is cleaned...use a new disposable towel soaked with 1:10 (one to ten) bleach solution and clean the area a second time...Use an appropriate disinfectant such as 1;100 (one to one hundred) bleach solution for routine disinfection of environmental surfaces....” Observations on March 18, 2024, revealed the following. 1. Dialysis chairs at stations #1 and #3, had both been cleaned with 1:100 bleach rags, after inspection of the chairs, both showed tape residue on the tray tables, the tape residue comes from the tape with a barrier that is placed when taping a patient upon initiation or termination of treatment. 2. Observation on March 18, 2024, revealed employee # 4 cleaning dialysis station #3. Employee #4 went to grab bleach rags and also picked up two hemostats, which employee #4 then placed on the IV pole that had not been sanitized. Employee #4 then proceeded to clean the machine, but the keyboard was not cleaned, when employee #4 cleaned the chair the same rag that had been used to clean the machine was used. Employee #4 cleaned the front of the television but failed to clean the back of the television, the arm that holds the television, or the emergency take-off bag that is attached to the television. Employee #1 confirmed on March 19, 2024, that the chairs and dialysis stations were not cleaned as per policy and procedure.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 45999 Based on a review of facility policies and procedures, observation on tour, and interview with staff, it was determined that the facility failed to require that staff monitor and keep the arterial drip chamber 85-95% full, which has the potential for air entering the bloodlines which can lead to a patient’s injury or death, due to an air embolism. Findings include: A review of facility policy titled, “ Initiation of Treatment Using an Arteriovenous Graft or Fistula and Optiflux Single Use Ebeam Dialyzer” revealed: “...The arterial chamber is 85-95% full ... monitor pressure changes in the arterial chamber to ensure adequate blood flow ... ensure that arterial chamber is filled to 85-95%....” Observation on a tour of the facility on March 18, 2023, revealed 3 of 12 dialysis machines with arterial drip chambers filled less than 85-95% full. The arterial drip chambers on the dialysis machines at stations #1, # 4, and #10 were filled less than 25-50% full. Employee #1 confirmed during an interview on March 19 ,2024, that the drip chambers should be filled to 85-95 % full.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 45999 Based on a review of facility policy, medical records, and staff interviews, it was determined that the facility failed to require clinical staff to notify the nurse and the nurse provided a documented intervention for 6 out of 9 patients reviewed when the patient’s blood pressure (BP) and/or heart rate (HR) was out of range per the facility policy, which poses the potential risk of cardiovascular compromise and hospitalization. Findings include: Facility policy titled, “...Patient Assessment and Monitoring....” published December 2022, revealed: “...Monitoring During Treatment...Report to the nurse: Systolic blood pressure greater than 180 mm/Hg, Diastolic blood pressure greater than 120 mm/Hg, Blood Pressure less than or equal to 90 mm/Hg systolic ... Any significant drop in Systolic blood pressure greater than 40mm/Hg ...Heart rates that have dropped below 60 or risen above 100 ...Report to the nurse any significant findings....” “...Treatment Sheets....” revealed: Patients #4, #5, #6, #7, #8, and #9 all had multiple treatment sheets with BP and HR out-of-facility parameters that were not found to have any documentation of Patient Care Technician (PCT) reported to the nurse or that the nurse assessed and/or treated out of rang BP and/or HR. Employee #1 confirmed, on March 19, 2024, that this practice was not following facility policy.”