Usrc Long Beach Dialysis

“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: 46333 Based on observation, interview, and record review, the facility failed to ensure that four (4) of five (5) sampled clinical care recliner dialysis chairs (Chairs 1, 2, 3, and 4) did not have holes and tears. The facility’s failure resulted in the facility inability to maintain infection control practices and patient safety for 56-62 patients (on Monday, Wednesday and Friday, the facility provides dialysis services to approximately 56 patients and on Tuesday, Thursday and Saturday, the facility provides dialysis services to approximately 62 patients) to whom the facility provided dialysis services. Findings: During a concurrent observation and interview on 8/29/24 at 2:10 p.m. with the Facility Administrator (FA) in the treatment area, there were 4 of 5 unoccupied recliner dialysis chairs with tears and holes as follows: Chair 1 had a linear tear at the center of the headrest, measuring 15 cm x 1 cm (a centimeter, a unit of measurement); Chair 2 had a linear tear on the seat, measuring 14 cm x 2 cm; Chair 3 had a hole at the footrest of about 3 cm x 3 cm; and an additional linear tear to the headrest, measuring 5 cm x 1 cm; Chair 4 has a linear tear on the seat, measuring 11 cm x 1 cm and there was additional damage to the headrest, with paper tape affixed to it, measuring 15 cm x 1 cm. The FA confirmed that the paper tape on Chair 4 could be a breeding ground for microbial growth and could not be cleaned appropriately. The FA confirmed that the tear in the dialysis chairs leaves crevices that couldn’t be cleaned properly if blood were to leak into the tears. The tears on the dialysis chairs is also uncomfortable for patients during their lengthy dialysis treatments.. To solve the issue, facility staff were told to repair the dialysis chairs with a vinyl patch, however the facility still needed to order the vinyl patch kit. The FA also confirmed that the facility did not have any other clinical care recliner dialysis chairs, beside the chairs observed in the treatment area. During an interview on 8/29/24 at 2:00 p.m. with the Regional Director of Operations (RDO), the RDO stated the chairs were reported by the FA as damaged in April 2024. The RDO stated the facility had placed orders in May for chairs; however, there was a manufacturing delay with providing the dialysis chairs that were ordered. They were expecting the order in June. The facility currently does not have any spare chairs in storage at the facility. The RDO stated, “What we are doing is patching the chairs with vinyl patches.” During an interview on 9/5/24 at 4:34 p.m. with the Director of Clinical Operation (DCO) and the FA, the DCO stated that, within the facility, there were eight dialysis chairs that were damaged. The DCO further stated the dialysis industry chairs and parts have been on backorder for several months now, and as an organization, “We have tried to be proactive as we wait for replacement parts and/or new chairs to arrive.” Part of that process was to cover the chairs identified as having an issue with plastic sheeting. This was discussed and agreed upon by the government body in April 2024. The FA confirmed that on 8/29/24, the facility did not have any other chairs besides those in the treatment area. Thus, there were three of the eight damaged chairs that were occupied by patients that did not have plastic covers on, as observed on 8/29/24. During a review of the facility Biomed Status Report in an email provided by the (DCO), dated July 2024, the Biomed Status report indicated, “findings: multiple chairs have wear and tear vinyl broken actuators. Monitor Procedure: Monthly. Action to Correct Deficiency: couple chairs have been replaced with new vinyl and mechanical actuator on 2/18/2024. Some still need replacement for vinyl waiting for parts to arrive. No ETA form vendor regarding parts repairs still ongoing. Management to start considering replacing chairs due to normal wear on seat cushions and backrest. New (name of manufacture) chair were placed for orders no ETA.” During a review of the facility’s policy and procedure (P&P) titled, “Infection Control and Precautions for All,” dated July 2023, the P&P indicated, “Cleaning and disinfection: Clean and disinfect the dialysis station (e.g., chairs, beds, tables, integrated keyboards, dialysis machines, ancillary equipment) after patient has vacated the station. Give special attention to cleaning control panels on the dialysis machines and other surfaces that are frequently touched and potentially contaminated with patients’ blood ...” During a review of the facility’s policy and procedure (P&P) titled, “Disinfection and Cleaning of Dialysis Machine Equipment,” dated July 2023, the P&P indicated, “To provide guidance on proper disinfection of the dialysis station, machine, equipment and surrounding surfaces with the appropriate method prevents the transmission of disease/infection to the dialysis population ... Complete surface disinfection at the end of each dialysis treatment after the patient has vacated the station. Clean chair by placing in the reclining position and swing arms out (if applicable) to clean seat, footrest, backrest and sides, armrest, inside of chair arms and chair frame and side tray tables. Return chair to its upright position when cleaning is complete.” During a review of the facility’s policy and procedure (P&P) titled, “Facility Space/Design and Safety. Requirements, “dated April 2023, the P&P indicated, “Facilities will provide a physical environment that protects the health and safety of patients staff and the public. The surrounding areas that are used by patients (e.g., stairwells, corridors, passageways) will meet local building and fire safety codes relating to design and space requirements for safe access, ingress, egress and patient privacy ... Patient treatment area will be designed and equipped to provide proper and safe treatments as well as privacy and comfort for patients.” These policies/procedures were not implemented by the dialysis facility to ensure a clean, safe, and comfortable environment for patients.”