Fkc Talleyville

“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: 44819 Based on observation, policy review, and staff interview, it was determined that the facility failed to perform hand hygiene during patient care for 1 of 10 (Patient #2) patient care observations. Findings include: Facility policy titled “Hand Hygiene” dated 11/6/2023 stated, “...Hands will be decontaminated...before...direct contact with patients...after contact with inanimate objects near the patient...” Facility policy titled “Post Treatment Fistula Needle Removal” dated 7/6/2021 stated, “...Person removing needles perform hand hygiene and don clean gloves...” Patient #2 During observation of the discontinuation of dialysis treatment on 4/29/24 between 9:45 AM and 10:25 AM, Employee #2 was observed completing the following tasks: - performed hand hygiene and donned clean gloves - returned Patient #2’s blood - clamped bloodlines and needle lines, then removed the bloodlines from the needle lines and removed Patient #2’s first needle - discarded the needle then removed his/her gloves and performed hand hygiene Employee #2 failed to perform hand hygiene and change gloves before removing Patient #2’s needle. Employee #2 confirmed this finding on 4/29/24 at 10:25 AM.”

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 48349 Based on observation, policy review, and staff interview, it was determined that the facility failed to ensure that soap was available to facilitate hand washing for 1 of 1 handwashing sinks in the “Lab Room.” Findings include: Facility policy titled “Hand Hygiene” dated 11/06/2023 stated, “...Sink Policy...Soap and a supply of paper towels protected from contamination must be available at each sink ...” During a tour of the facility on 4/29/24 between 9:15 AM and 9:25 AM in the room labeled “Lab Room,” it was observed that no hand soap was available at the handwashing sink. The canister which holds the hand soap was empty and no soap refills were located in the “Lab Room”. During an Interview on 4/30/24 at 8:31 AM, Employee # 8 confirmed the above finding.”

“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: 48349 Based on observation, policy review, and staff interview, it was determined that the facility failed to maintain a safe and sanitary environment for 31 of 31 patients at the dialysis facility on 4/29/24 and 4/30/24. Findings include: Facility policy titled “Storage of Supplies” dated 4/05/2021 stated, “...Proper storage conditions are necessary to provide a safe environment and to ensure supplies are not expired, contaminated, or damaged...All clean or sterile supplies...must be stored off the floor and a minimum of eighteen inches in a sprinklered facility from the ceiling...All liquid supplies must be stored separate from dry supplies to minimize damage from accidental breakage or spill...” Facility policy titled “General Cleanliness and Infection Control Guidelines” dated 2/7/22 stated, “...All areas must be kept clean and organized...solutions will be stored and labeled per policy...” During a flash tour of the room labeled “Janitor Closet” on 4/29/24 between 9:25 AM and 9:35 AM, the following was observed: - A bottle of Clorox Bleach cleaning product was stored on a shelf next to a large roll of hand paper towels. The roll of hand paper towels had a visible wet spot, 4 inches in diameter, on the side of the roll and was positioned next to the bottle of Clorox Bleach cleaning product. - A cardboard box was stored less than 18 inches (approximately 6 inches) from a sprinkler head. - A spray bottle with an unknown liquid inside was not labeled with the contents. During an interview on 4/29/24 at 9:41 AM, Employee #8 confirmed the above findings. During a tour of the room labeled “Storage” and “Training Room” on 4/30/24 between 10:18 AM and 10:33 AM, the following was observed: - Three (3) open paint cans were stored on the floor. - A rag in the corner of the room was covered with rodent feces. During an interview on 4/30/24 between 10:20 AM and 10:33 AM, Employee #15 confirmed the above findings.”

“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: 44819 Based on observation and staff interview, it was determined that the Facility failed to maintain its facility to ensure the safety of 31 of 31 patients at the dialysis facility on 4/29/24 and 4/30/24. According to the 2012 Life Safety Code, “...Main and feeder circuit breakers are inspected annually...” During a facility tour on 4/30/24 between 10:18 AM and 10:33 AM it was observed that the main electrical panel was last inspected on 8/21/2017. Upon request, the Facility could not provide evidence that the main electrical panel has been inspected annually since 8/21/2017. During an interview on 4/30/24 at 10:33 AM, Employee #15 confirmed this finding.”

“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: 48349 Based on observation, policy and document review, and staff interview, it was determined that for 32 of 32 current patients, the facility failed to ensure that supplies and equipment were maintained according to the manufacturer’s directions for use and/or were used within the manufacturer’s recommended expiration dates. Findings include: I. Expired Supplies in “Lab Room” Facility policy titled “Storage of Supplies” dated 4/05/2021 stated, “...Proper storage conditions are necessary to provide a safe environment and to ensure supplies are not expired, contaminated or damaged...Supplies must be rotated First-in-First Out (FIFO) to ensure products maintain quality and do not expire. Appropriately dispose of items that have reached the expiration date...” A flash tour of the room labeled “Lab Room” was completed on 4/29/24 between 9:15 AM and 09:24 AM. It was observed that a total of eight (8) blood draw tubes were expired. The expired items included: - Seven (7) “BD Vacutainer no additive” tubes (Lot #2259048, Reference # 366703) with an expiration date of 3/31/24. - One (1) “BD Vacutainer K2 EDTA” tube, (Lot # 2321385, Reference # 367861) with an expiration date of 3/31/24. During an interview on 4/29/24 at 9:39 AM, Employee #8 confirmed the above findings. II. Expired Supplies on Emergency Cart Facility policy titled “Emergency Medications, Equipment and Supplies” dated 05/01/2023 stated, “...Emergency Cart...Items approaching expiration must be reordered and replaced prior to the actual expiration date...” During an inspection of the facility’s emergency cart on 4/29/24 between 10:13 AM and 10:44 AM it was observed that 6 out of 12 “Sysloc Mini Safety A.V. Fistula Needle Sets” (Lot # 190328331, Reference # 864-1500-33) located in the emergency cart had an expiration date of 3/28/2024. During an interview on 4/29/24 between 10:38 AM and 10:44 AM, Employee #6 confirmed the above finding. III. Storage room with equipment not labeled for use. Facility policy titled, “Use of Hemodialysis & Ancillary Machine Repair/Return Tag” dated 11/04/2019 stated, “...The Standard Repair Request tag will be filled out and affixed to the hemodialysis machine or ancillary equipment whenever it is removed from service...Only the Standard Repair Request tag will be used to label machines removed from service. No other tagging system will be used... The Standard Ready for Use tag will be filled out and affixed to the hemodialysis machine or ancillary equipment whenever a machine is ready to return to service...” During a tour of the “Storage Room” on 4/30/24, it was observed that numerous pieces of equipment were not labeled for use. It could not to be determined if the equipment needed service or was ready for use. The equipment not labeled for use included: - Hoyer lift with inspection sticker dated “due” on 7-2021 (Serial # 1004L0567, Model #HPL 402) - Hoyer lift with inspection sticker dated “due” on 10/2023 (Serial # 1902L0692, Model #HPL902) - Portable RO Machine, Manufacturer “Better Water LLC” (Serial #1410144) - Portable RO Manufacturer, Manufacturer “Better Water LLC” (Serial #1410140) - Portable RO Manufacturer “Mar Cor” Serial #1320284 not labeled for use - Water Quality Monitor, Manufacturer “Better Water LLC” (Model #EQRO-1232-2800- 01001 Serial #EQR01508006) - Helmer medication fridge (Asset #2127773) - Three (3) Tan recliner chairs, Manufacturer “Winco” During an interview on 4/29/24 between 10:18 AM and 12:05 PM, Employee #15 confirmed the above findings.”

“POC-MANAGE ANEMIA/H/H MEASURED Q MO CFR(s): 494.90(a)(4) The interdisciplinary team must provide the necessary care and services to achieve and sustain the clinically appropriate hemoglobin/hematocrit level. The patient’s hemoglobin/hematocrit must be measured at least monthly. The dialysis facility must conduct an evaluation of the patient’s anemia management needs. This Standard is not met as evidenced by: 44819 Based on medical record review, Facility policy and protocol review, and staff interview, it was determined that for 1 of 4 patients (Patient #1) in the medical record review sample, the interdisciplinary team failed to ensure services to achieve the desired/appropriate hemoglobin level goal. Findings include: Facility algorithm titled “Corporate MAB [CMAB] Recommended Anemia Algorithm Mircera IVP [intravenous push] Administration (InCenter Only) Version 4.0” dated August 2019 documents that when the hemoglobin level is between 10.6 and 11.2, the Mircera dose should be decreased from maintenance dose of 60 mcg (micrograms) to 50 mcg every 2 weeks. Patient #1 Medical record review revealed: - Physician orders dated 5/1/2023 for CMAB recommended anemia algorithm for Mircera IVP Administration (InCenter only) version 4.0 - ESA (erythropoietin-stimulating agent) details in the “Treatment Sheet” dated 4/8/24 documented the patient is to receive Mircera 60 mcg IVP (intravenous push) every 2 weeks with the last dose received on 4/1/24. - Report of hemoglobin value dated 4/10/24 documents result of 10.7. According to the ordered algorithm, the next Mircera dose should be decreased to 50 mcg. - “Treatment Sheet” dated 4/15/24 documents patient received 60 mcg Mircera. During an interview on 5/1/24 at 10:05 AM, Employee #8 confirmed that staff failed to follow the ordered protocol to decrease Patient #1’s Mircera dose to 50 mcg on 4/15/24.”