032635 Gilbert Dialysis (Fmc)

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 45999 Based on a review of facility policy, daily water treatment logs, and staff interview, the Department determined that the facility failed to ensure staff notify the facility administrator (FA) and/or Biomed technician (BMT) and appropriate action was taken when the end of day hardness test result was above the acceptable limits specified on the daily water treatment log for two (3) of (3) months reviewed, failure to maintain water logs per facility policy poses the potential risk of harm to patients and hospitalization if the water system were to malfunction. Findings include: Facility policy titled “Carbon Filtration Monitoring for Incenter Central Water Systems Policy” revised November 7, 2022, revealed: “... Two trained staff members, one of whom must be a licensed registered nurse (RN), will perform and verify total chlorine testing ...The Reverse Osmosis machine (RO) must be running alarm-free and within normal operational parameters for at least 15 minutes prior to obtaining water samples for total chlorine testing ...Flush the sample port for 2 minutes prior to collecting the sample ...The Worker Carbon Filter must be checked prior to initiation and at a minimum of every four hours ....” Observation of the hourly total chlorine logs on March 25, 2024, revealed: January 27, 2024, the check was late by one minute February 2, 2024, the entry for time checked was missing February 15, 2024, the entry was late by 30 minutes February 26, 2024, the entry was late by 5 minutes March 1, 2024, the entry was late by 1 minute March 2, 2024, the entry was late by 1 minute March 9, 2024, the entry was late by 15 minutes March 14, 2024, the entry was late by 15 minutes March 16, 2024, the entry was late by 2 minutes March 18, 2024, the entry was late by 2 minutes March 23, 2024, the entry was late by 9 minutes Employee #1 confirmed during an interview conducted on March 26, 2024, that the daily water treatment logs were not following the policy and procedure for checking the total chlorine daily or hourly.”

“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 observation and staff interview, the Department determined that the facility failed to ensure the facility is free from a condition or situation that may cause an individual to suffer a physical injury; Failure to maintain structural integrity, and possible spreading of infectious disease, Multiple patient health and safety risks including but not limited to infection control breaches. Observation on March 25, 2024, revealed a pillar between patient stations #5 and #6, that was rusted and corroded along the bottom and spots of rust also running up the pillar. Employee #15 confirmed in an interview on March 25, 2024, that the pillar does need to be repaired and confirmed that there is no work order for repair at this time.”

“GOV-RN, MSW, & RD AVAIL TO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- The registered nurse, social worker and dietitian members of the interdisciplinary team are available to meet patient clinical needs; This Standard is not met as evidenced by: 49430 Based on record review, and interview, the facility did not ensure that it had an adequate number of Licensed Social Workers to meet the clinical needs of each patient. Lack of adequate psychosocial status assessment and interventions put the patient population at increased risk for noncompliance to treatments, late or inaccurate interdisciplinary plans of care increasing the risks of hospitalizations, decreased function and death. Finding includes: During interview on 03/26/2024, Employee #1 confirmed the social worker “has around 170 patients on the census that they are responsible for”. Employee #1 confirmed there is only 1 social worker assigned to the clinic but if help is needed, social worker can request assistance from direct supervisor. Employee #1 confirmed the multiple late KDQOL assessments were directly related to ratio of patients to social worker ratio. During interview on 03/26/2024, employee #2 confirmed the typical, average patient census for social workers is around 140 patients. Employee #2 confirmed via instant message with employee #1 direct supervisor that 140 patients is the typical social worker census. When asked “what actions are being implemented to correct the issue, Employee #2 responded that leadership is looking at reorganizing the coverage area for this social worker. When asked when the corrections would be made, no response was given. During chart reviews, multiple late KDQOL assessments were noted. During review of Governing Body minutes, action plans for late KDQOL assessments were noted in the Meeting Mintes as far back as January 2024.”