032617 Tucson West 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: 37489 Based on document review, observation, and interview, it was determined that the facility failed to ensure staff performed hand hygiene between glove changes and donned clean gloves when providing patient care which has the potential risk of increased infection for patients through cross contamination and contact transmission. Findings include: The facility policy titled “Hand Hygiene” requires: “...Purpose...to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination...Hands will be...Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water...Before and after direct contact with patients...Entering and leaving the treatment area...Before performing any invasive procedure...Immediately after removing gloves...After contact with inanimate objects near the patient...When moving from a contaminated body site to a clean body site of the same patient...After contact with the dialysis wall box, concentrate, drain, or water lines...After contact with other objects within the patient station or treatment space....” Observation on 12/29/2025, revealed Employee #12 providing patient care. Employee #12 donned a pair of gloves without performing hand hygiene, then retrieved a second pair of gloves which remained in his right hand while escorting a patient from the lobby to the treatment area. Employee #12 took the patient’s temperature with his gloved right hand and extra gloves, walked the patient to the scale and reset some buttons for the scale with his gloved hand, walked the patient to station #15, left the station, walked to station #22 to talk to another employee, then walked to station #24 and touched the machine. Glove changes and hand hygiene were not observed to take place between any of the patient care tasks. Employee #12 was observed re-gloving in the same manner two additional times during the observation. One set of gloves were donned with a second set of gloves retrieved and held in his right hand while providing care. One occurrence the employee did not hand sanitize prior to donning the first set of gloves, and on the second occurrence the employee donned the dirty second set of gloves without performing hand hygiene between glove changes. Employee #1 confirmed on 12/29/2025, that Employee #12 did not perform hand hygiene and glove changes as required by facility policy.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 37489 Based on document review, observation, and interview, it was determined that the facility failed to ensure staff wore appropriately maintained fluid resistant gowns while providing patient care which has the potential for contamination of clothing and spread of infection throughout the facility. Findings include: The facility policy titled “Personal Protective Equipment” requires: “...Gowns ...Personal protective fluid resistant gowns must be changed whenever visibly soiled or in disrepair ....” Observation on 12/29/2025, revealed Employee #12 providing patient care in the treatment area. Employee #12 ’ s fluid resistant gown was torn in the front with a large hole approximately 4 inches in diameter with the ties torn off and the gown fluttering around the employee as he walked around the facility. Employee #1 confirmed on 12/29/2025, that Employee #12 ’ s gown was torn and worn inappropriately while providing patient care.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 37489 Based on document review, observation, and interview, it was determined that the facility failed to ensure staff thoroughly cleaned and disinfected the dialysis station after use which has the potential risk of spread of infection between patients. Findings include: The facility policy titled “Cleaning and Disinfecting the Dialysis Station” requires: “...General Cleaning...The dialysis station could become contaminated with blood and other body fluids during treatment...Externally disinfect the dialysis machine with 1:100 bleach solutions after each dialysis treatment....” Observation on 12/29/2025, revealed Employee #9 cleaning and disinfecting the vacated dialysis station #21. Employee #9 failed to disinfect all surfaces of the machine with bleach solution, missing the hangers on the IV pole, the TV arm, and missed sections of upholstery on the dialysis chair. Observation on 12/29/2025, revealed Employee #3 cleaning and disinfecting the vacated dialysis station #15. Employee #3 failed to disinfect all surfaces of the machine with bleach solution, missing the upper portion of the IV pole above the machine bracket, the IV pole hangers, and missed sections of upholstery on the dialysis chair. Observation on 12/29/2025, revealed 3M Transpore plastic medical tape used to tape machine components (YubiKey scanner device) onto the dialysis machine. The tape and tape residue was not removed to clean and disinfect the dialysis machines between patients at stations #11 and 14. Employee #1 confirmed on 12/29/2025, that dialysis machines and equipment at the patient stations were not cleaned and disinfected as required.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 37489 Based on document review, observation, and interview, it was determined that the facility failed to ensure: 1. staff appropriately labeled multi-dose Heparin and Lidocaine medication vials when opened. Failure to label medication vials when opened with an appropriate expiration date prevents staff from knowing when to discard the vial which increases the risk a patient will receive a medication that is no longer stable, and that may be contaminated due to reduction of preservative efficacy as well as an increased exposure to pathogens from accessing a vial multiple times; and 2. predrawn medications were labeled appropriately which has the potential risk for patients to receive incorrect, or expired medications which can have adverse effects on the patient ’ s health. Findings include: 1. and 2. The facility policy titled “Medication Preparation and Administration” requires “...When preparing medications if the vial is not used immediately in its entirety, the nurse or PCT (if allowed by state regulations), must place the date and time the vial was opened on the medication label along with their initials ...Any open multidose vials must be discarded 28 days after opening or per manufacturer ’ s expiration date ...Medications may be pre-drawn up to 4 hours prior to administration. These pre-drawn medications shall be labeled ....” 1. Observation on 12/29/2025, revealed an opened 30 ml vial of Heparin Sodium labeled with an open date of 12/25/29, and an open and in-use, unlabeled 20 ml vial of Lidocaine Hcl. Both medications were found in the medication cabinet at the nurses station. Employee #1 confirmed on 12/29/2025, that the open, in-use vials of Heparin and Lidocaine were not labeled as required by facility policy. 2.Observation on 12/29/2025 revealed pre-drawn medication syringes in the medication cabinet at the nurses station. Three (3) 10 ml syringes of Heparin Sodium were labeled for Patients #9 and 11; however, there was no time that the medication was prepared or initials of the preparer written on the label. Additionally, two (2) 3 ml syringes contained an unknown, clear fluid that was not labeled with the contents of the syringes. Employee #1 confirmed on 12/29/2025, that the pre-drawn Heparin was not labeled with the time the medication was prepared and that two additional syringes in the medication cabinet contained unknown solutions and were not labeled 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: 37489 Based on document review, observation, and interview, it was determined that the facility failed to ensure (9) of (24) dialysis station chairs did not have torn and cracked vinyl that exposed underlying padding. Failure to maintain intact vinyl on dialysis chairs poses a risk of infection though cross contamination as exposed foam and fabric on the chair may harbor potentially infectious material that cannot be cleaned and disinfected. Findings include: The facility policy titled “Equipment Installation-Operation-Maintenance-Repair-and Disposal” requires: “...Dialysis Chairs ...Any equipment or device that is not fully functioning in accordance with IFU or company policy, must be repaired or replaced as soon as reasonably possible ...If the faulty equipment poses a risk to the patient or staff, the device will be immediately removed from service ....” Observation on 12/29/2025 revealed (9) of (24) dialysis chairs in use on the treatment floor had torn and cracked upholstery in various locations on the chairs including arm rests, foot rests, and head rests. The tears in the chairs ranged from 1/4 inch to 6 inches long and 12 inches wide with exposed underlying fabric backing and foam. Areas with multiple large sections of cracks were in areas patient ’ s heads routinely rested and were unable to be cleaned. Employee #1 confirmed on 12/29/2025 that the observed chairs were in disrepair with torn and cracked vinyl that prevented appropriate disinfection between patients. Additionally, the facility leadership was aware of the deficient practice and had not replaced or repaired the chairs to date.”