Usrc Northeast Phoenix

“IC-CDC MMWR 2001 CFR(s): 494.30(a) The facility must demonstrate that it follows standard infection control precautions by implementing- (1)(i) The recommendations (with the exception of screening for hepatitis C), found in “Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients,” developed by the Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, volume 50, number RR05, April 27, 2001, pages 18 to 28. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html. The recommendation found under section header “HBV-Infected Patients”, found on pages 27 and 28 of RR05 (“Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients”), concerning isolation rooms, must be complied with by February 9, 2009. This Standard is not met as evidenced by: 49430 Based on review of policy/procedure, observation, and staff interview, it was determined that the facility failed to ensure; 1. staff aseptically maintained vascular access prior to disconnection of fistula needles and; 2. staff appropriately cleansed (3) of (3) patients’ (Patient #13,#15, and #16) vascular access prior to cannulation with fistula needles. Failure to practice safe aseptic technique when cleansing and disinfecting a patient’s vascular access and use clean supplies for securing needles and ports increases the risk for vascular access and blood stream infection. Findings include: 1. The facility policy titled “Termination of Treatment” requires “...10. Prior to disconnecting bloodlines, check patients sitting and standing...blood pressure....” 1. Observation on 1/16/2024 revealed Employee #11 at station #15, disconnected both the arterial and venous blood lines, allowing the fistula needle ports to be clamped and not securing the ends with any device, leaving the open ports open to air and dangling from the patient’s arm, standing the patient for a standing blood pressure, then reseating the patient and then removing fistula needles. 1. Employee #1 confirmed on 1/16/2024 and that the practice of allowing uncapped fistula needles to hang from the patients arm while PCT takes a standing BP is not per the facilities policy. 2. The facility policy titled “Assessment and Cannulation for AV Fistula/Graft and Patient Self Cannulation” requires “...Alcohol Prep Pad...Utilize a rubbing motion for at least 30 seconds...”. The facility policy titled “Assessment and Needle Placement for Existing and New Fistula and Graft” requires: “...Access preparation...Disinfect each assess site separately with one of the below options: Alcohol prep pad in a rubbing motion for at least 30 seconds immediately prior to needle insertion....” 2. Observation on 1/16/24 revealed Employee #10 access a patient’s fistula site at chair #13. Employee # 10 scrubbed the initial site for 24 seconds with and alcohol pad then cannulated with the red needle. Employee #10 then scrubbed the second site for 16 seconds with alcohol prior to cannulated with the blue needle. 2. Observation on 1/16/24, revealed Employee #6 prepared to cannulate Patient #15’s vascular access. Employee #6 used an alcohol pad to disinfect the arterial cannulation site for 29 seconds prior to cannulating the site. Employee #6 used an alcohol pad to disinfect the venous cannulation site for 33 seconds prior to cannulating the site. 2. Observation on 1/16/24, revealed Employee #9 prepared to cannulate Patient #’16’s vascular access. Employee #9 used an alcohol pad to disinfect the arterial cannulation site for 27 seconds prior to cannulating the site. Employee #9 used an alcohol pad to disinfect the venous cannulation site for 31 seconds prior to cannulating the site. 2. Employee #1 confirmed on 1/16/2024 and that this practice was not following facility policy. Observation on January 16, 2024, revealed Employee #6 prepared to cannulate Patient #’s vascular access. Employee #6 used an alcohol pad to disinfect the arterial cannulation site for 29 seconds prior to cannulating the site. Employee #6 used an alcohol pad to disinfect the venous cannulation site for 33 seconds prior to cannulating the site. Observation on January 16, 2024, revealed Employee #9 prepared to cannulate Patient #’s vascular access. Employee #9 used an alcohol pad to disinfect the arterial cannulation site for 27 seconds prior to cannulating the site. Employee #9 used an alcohol pad to disinfect the venous cannulation site for 31 seconds prior to cannulating the site. Employee #1 confirmed on January 17, 2024, that Employees #6,#7, and # did not clean the patient’s access sites as per policy and procedure.”

“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: 45999 Based on document review, observation, and interview, it was determined that the facility failed to ensure staff cleaned/disinfected stethoscopes before and/or after use which has the potential for cross contamination and increased infection. Findings include: The facility document titled “Infection Control and Precautions for ALL Patients” requires: “...3. Clean areas will be clearly designated and separated from contaminated areas and unused supplies and equipment.... 13. Supplies: Times taken into the dialysis station will 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. a. Non-disposable items that cannot be cleaned and disinfected...will be dedicated for use only on a single patient....”. Observation on 1/16/2024 revealed Employee #5 used a stethoscope to assess patient at chair #9 then proceed to assess patient in chair #10 without cleaning/disinfecting stethoscope between patients. Employee #1 confirmed on 1/16/2024 that stethoscopes must be disinfected unbeaten patient assessments.”

“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 policy, observation on tour, facility documents, and interviews, the Department determined that the facility failed to ensure checked medications for expiration dates on a monthly basis. Failure of staff to follow facility policy regarding medication expiration dates has the potential risk of using expired medications for patients which could lower the drugs’ effectiveness or make it toxic. Findings include: A policy titled “Facility Space/Design and safety requirements”, revealed, “ ....Ensure all supplies, medications, and test strips are checked at least monthly ...” Observation on tour on January 16, 2024, revealed expired supplies and medications: 181- Monoject 3ml syringes with needles, expired 11/30/2022 1-BD Vacutainer Safety Lok Blood Collection Set expired 4/20/23 186-Povidone Iodine Prep Pads expired 10/2023 1-FlexiCap Disconnect Cap expired 12/28/2023 Employee # 1 confirmed that the expiration dates were not being verified monthly as per policy and procedure.”

“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: 45999 Based on document review, observation, and interview, it was determined that the facility failed to ensure medications in the treatment area were locked and secured to prevent unauthorized access. 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: The facility policy titled “Guidelines for Administration of Medication “ requires: “...16...a. Medications will be locked in a cabinet or a medication refrigerator.....” Observation on 1/16/2024 revealed an unsupervised, unlocked drawer at the technician/nurses’ station across from chair #4 containing a pre-drawn syringe of Heparin. Another pre-drawn syringe of Heparin was observed to be sitting, unsupervised/unlocked on the table at chair #7 with no patient or staff present at chair #7. Employee #1 confirmed on 1/16/2024 that the medications were left unlocked and not secured as required by facility policy.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. 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, the Department determined that the facility failed to require that staff monitor and keep arterial drip chambers 85-95% full or to the manufacturer’s fill line indicator 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 the facility policy titled, “Priming the Extracorporeal Circuit (CombiSet, NiproSet, and Streamline Bloodlines)” revealed: “...PROCEDURE: Clamp the main line clamp on the arterial line ...Loosen the arterial side arm tubing cap to fill the arterial chamber to 85-95%, tighten cap and clamp the arterial monitoring line...” Observation on a tour of the facility on January 16, 2024, revealed 4 of 16 dialysis machines with arterial drip chambers filled less than 85-95% full. The arterial drip chambers on the dialysis machines at stations 3, 6, 7, and 8 were filled less than 25% full. Employee #1 confirmed during an interview on January 17, 2024, that the drip chambers should be filled to 85-95% full.”