Rai 9th Street North - St Petersburg

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9. 20.2.9.1, 21.2.9.1, 7.9 This Standard is not met as evidenced by: 40620 Based on record review and interview, the facility failed to maintain emergency battery back-up lighting in accordance with NFPA 101. Findings include: On 8/28/2024 between 9:30 a.m. and 12:00 p.m., during record review with the facility staff, the facility failed to provide documentation of the emergency battery back-up lighting annual 90-minute testing. An interview was conducted with the facility staff concurrent with the record review and confirmed the findings. NFPA 101 (2012 Edition) 19.2.9.1, 7.9.3.1.1(1)through(5)”

“Fire Alarm System - Out of Service CFR(s): NFPA 101 Fire Alarm - Out of Service Fire alarms that are out of service for 4 hours in a 24 hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. 9.6.1.6 This Standard is not met as evidenced by: 40620 Based on observations and interview, the facility failed to maintain the Fire Alarm System as required by NFPA 101. Findings Include: On 8/28/2024 between 12:30 p.m. and 1:30 p.m., during the tour of the facility with the facility staff, the Fire Alarm Control Panel was observed showing a blank screen and not working. The staff advised that the alarm panel quit working after a lightning strike about two weeks ago. An interview was conducted with the facility staff concurrent with the observations and confirmed the findings. NFPA 101 (2012 Edition) 21.3.4.1, 9.6.1.3, 9.6.1.6 NFPA 72 (2010 Edition) 14.5.1, 10.19”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 40620 Based on a review of the facility records and interview, the facility failed to maintain the Automatic Fire Sprinkler System (AFSS) in accordance with NFPA 101. Findings include: On 8/28/2024 between 9:30 a.m. and 12:00 p.m., during record review with the facility staff, the facility failed to provide documentation of the annual and semi-annual AFSS inspection. An interview was conducted with the facility staff concurrent with the observations and confirmed the findings. NFPA 101 (2012 Edition) 21.7.6, 4.6.12, 4.6.12.1, 9.7.5 through 9.7.8 NFPA 25 (2011 Edition) 4.1, 4.1.1, 4.1.1.1, 5.2, 5.3, 5.4”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 21.7.1.4 through 21.7.1.7 This Standard is not met as evidenced by: 40620 Based on a review of the facility records and interview, the facility failed to conduct fire drills as required by NFPA 101. Findings Include: On 8/28/2024 between 9:30 a.m. and 12:00 p.m., during the record review with the facility staff, the facility failed to provide documentation of the quarterly fire drills. An interview was conducted with the facility staff concurrent with the record review and confirmed the findings. NFPA 101 (2012 Edition) 21.7.1.6, 21.1.1.3.2(3), 4.7.2”

“Maintenance, Inspection & Testing - Doors CFR(s): This Standard is not met as evidenced by: 40620 Based on a review of the facility records and interview, the facility failed to maintain the Fire Doors in accordance with NFPA 80. Findings include: On 8/28/2024 between 9:30 a.m. and 12:00 p.m., during record review with the facility staff, the facility failed to provide documentation of the annual fire door inspections. An interview was conducted with the facility staff concurrent with the observations and confirmed the findings. NFPA 101 (2012 Edition) 21.7.6, 4.6.12 NFPA 80 (2010 Edition) 5.2, 5.2.1”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For, LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 40620 Based on a review of the facility records and interview, the facility failed to maintain electrical inspections in accordance with NFPA 99. Findings include: On 8/28/2024 between 9:30 a.m. and 12:00 p.m., during record review with the facility staff, the facility failed to provide documentation of the annual receptacle testing. An interview was conducted with the facility staff concurrent with the record review and confirmed the findings. NFPA 99 (2012 Edition) 6.3.3.2 through 6.3.3.2.4”

“Electrical Equipment - Testing and Maintenanc CFR(s): NFPA 101 Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility’s policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8 This Standard is not met as evidenced by: 40620 Based on a review of the facility records and interview, the facility failed to inspect patient care equipment in accordance with NFPA 99. Findings include: On 8/28/2024 between 9:30 a.m. and 12:00 p.m., during record review with the facility staff, the facility failed to provide documentation of the annual Bio Medical Patient Care Equipment. An interview was conducted with the facility staff concurrent with the record review and confirmed the findings. NFPA 99 (2012 Edition) 10.5.2.1.1, 10.5.2.1.2”

“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: 34768 Based on observation, interview, and record review the facility failed to ensure the staff followed infection control precautions for two of four sampled patients (#16 and #18) during observation of one discontinuing of the AV (Arteriovenous) fistula post dialysis and one accessing a Central Venous Catheter (CVC) for initiation of dialysis. Staff did not follow infection control practices during disinfection of dialysis chairs, a liquid acid concentrate jug opened at chair side, and long fingernails. Findings included: 1. On 08/26/2024 at 12:15 p.m., Patient #16 was observed to have his Central Venous Catheter (CVC) accessed for dialysis by Staff J, Patient Care Technician (PCT). The patient did not have a surgical mask in place. The gauze covered ports were placed on the drape. The CVC exit site dressing was removed, and Staff J cleaned the site while also touching the patient’s shirt. Staff J applied gauze over the exit site. Staff J then removed her gloves and left the patient area to get a mask for the patient. She re-applied her gloves. Staff J removed the gauze from over the ports and laid the ports back on the drape. Staff J cleaned the ports and flushed with saline. Staff J removed her gloves and re-applied her gloves without hand hygiene. Staff J inputted into the dialysis machine. Staff J tested the water of the dialysis machine. When she returned to the patient area, one of the dialysis tubing fell onto the floor. She went to the supply drawer for another tubing (gloves in place). Staff J picked it up and removed it. Staff J then removed the entire dialysis set up and placed it in the disposal. She removed her gloves, went to the supply drawer for more supplies and returned re-applying her gloves. She reset up the dialysis machine. Staff J completed the connection to the dialysis machine. 2. On 08/26/2024 at 3:00 p.m. Staff Q, PCT was observed removing her gloves and reapplying gloves without hand sanitizing when she left Patient #17 chair side to go to another patient’s chair. 3. On 08/26/2024 at 3:15 p.m. Staff Q, PCT was observed discontinuing dialysis for Patient #18 with an AV fistula. Staff Q touched her face shield while her gloves were in place. She placed a glove on the patient’s hand and touched her face shield again. She then removed the cannulating needle, applied gauze to the site and placed the patient’s hand on the gauze for pressure. Staff Q, PCT removed the second cannulating needle and placed gauze and a clamp in place. She adjusted her face shield again and then to the dialysis machine for documentation. She removed her gloves and hand sanitized. 4. On 08/26/2024 it was observed three of the floor staff had long painted fingernails. The Director of Operations (DO) reviewed the policy and stated the staff were not to have finger nails longer than ¼ inch beyond their fingers. During an interview on 08/27/2024 at 12:16 p.m. the Director of Operations (DO) and the Home Dialysis Training Nurse stated the gauze dressing around the CVC ports would be considered dirty, but the facility does not have a policy for it. The drape would be dirty after lying the gauze covered ports on the drape, but it would not be contaminated. She stated the ports were dirty period. The staff was educated to remove the caps and scrub the hubs and attach syringes. The DO confirmed not hand sanitizing between glove changes was not a good practice. She confirmed touching the patient’s shirt with clean gloves and moving to another area during care and not hand sanitizing was not good practice. The DO stated it was not good practice to remove gloves, go to the supply drawer and get supplies then re-glove without hand sanitizing. The DO stated the supply drawers were considered “clean” areas. Stated she believed it was not a correct practice but had no policy regarding. The DO stated not a good practice for the staff to touch their face shield with their gloves on, etc. Face shields are dirty surfaces. The DO stated they do monthly infection control audits. They do a percentage of the staff, but it was not a set percentage of staff. They do different days of the week and shifts to encompass all the staff. They do track who has been audited and who has not. The staff was educated at least yearly and up to six times a year. Record review of the facility’s policy, “Changing the Catheter Dressing Procedure,” dated 02/05/2024 showed 2. Apply mask to patient and caregiver to help prevent contamination by airborne nasal bacteria. 3. Perform hand hygiene. 4. Don clean gloves. 5. Inspect and remove the old dressing. 8. Discard dressing and remove gloves. Perform hand hygiene. Cleaning the Site: 1. Perform hand hygiene and don clean gloves. 2. Remove swab stick from package by the sick end without touching foam applicator. Applying the Dressing: 1. Using aseptic technique, apply the catheter dressing over dry exit site, being careful not to touch the patient side of the dressing with gloved hands or to any surface. Record review of the facility’s policy, “Employee Dress Code,” dated 06/18/2021 showed fingernails must be clean and no more than ¼ of an inch beyond the tip of the finger. Record review of the facility’s policy, “Hand Hygiene,” dated 11/06/2023 showed the purpose of this policy is to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination. Policy: Hand hygiene includes either washing hands with soap and water or using a waterless alcohol-based antiseptic hand rub with 60-90% alcohol content. 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 such as vascular access cannulation or administration of perennial medications. “ Immediately after removing gloves. “ After contact with body fluids or excretion, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled. “ 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. Caution regarding fingernails “ Do not wear artificial fingernails, extenders or nail wraps when having direct contact with patients. “ Natural fingernail length shall be kept to 1/4 inch or less. Record review of the facility’s policy, “Infection Control Overview,” dated 05/02/2022 showed Infection Control Policies includes, but are not limited to: “ safe and efficient handling and disposal of waste and contaminants. “ Effective cleaning of blood contaminated linens and clothing 20536 5. On 8/26/2024 at 10:20 a.m. the “first floor” dialysis floor, where patients receive their treatment was toured and observed. A Dialysis machine station #2 was observed with a patient who had just finished her treatment and got up from the chair and left. Staff decontaminated and sanitized the machine and chair prior to the next patient treatment. At 10:53 a.m. A new patient (Patient #15) sat down at the chair/dialysis machine to receive treatment. Prior to Patient #15 sitting down, the machine was previously observed while the previous patient was seated there. There was a one gallon jug about one quarter full of Naturalyte. It was observed the red plug cap and tubing was not fully secure on the jug. The cap/plug was lifted off the top of the jug and with the fluid inside exposed to the elements in the room. After Patient #14 sat down to receive her treatment, staff still did not plug or close this cap and did not secure the opening of this jug. At 11:30 a.m. Patient #15 was still seated at station #2 receiving dialysis treatment. The Naturalyte jug was still uncapped and unplugged. Photographic evidence was obtained. On 8/26/2024 at 11:35 a.m. an interview with the Registered Nurse supervisor Staff A, confirmed the Naturalyte jug was left uncapped and the red plug should have capped the one gallon jug and to also ensure the tubing inside was secured. He confirmed the practice is to not leave this jug open and uncapped. 6. On 8/26/2024 at 10:25 a.m. the first floor dialysis treatment floor was observed. A clean counter space with clean/sanitized equipment and boxes of new gloves, and an open box of plastic gloves was observed. Further observations revealed an unsecured electronic cell phone. This phone did not belong to any patients in the area and at the time of the observation. Photographic evidence was taken. At 11:40 a.m. the electronic phone device was still on the clean counter. An interview with Registered Nurse supervisor Staff A confirmed the phone and revealed it must be one of the floor staff, and that any personal items should be kept on their person or in their bags. He revealed the phone definitely should not be placed in an area that is clean/sanitized and that has clean/sanitized equipment. 7. On 8/26/2024 at 9:51 a.m. Personal Care Technician (PCT) Staff G was observed disinfecting Station #2 after a patient was competed with her treatment. Staff G was observed using a chemical/sanitizer wipe on machine #2 and then the proceeded to walk over twenty feet to a counter area that had clean supplies on it. This counter area was in the middle of the room and had various supplies. Staff G took off her left glove and threw it in a trash container. She then grabbed a new glove and re gloved her left hand. Staff G did not wash her hands, nor sanitized her left hand prior to re gloving. Staff G never removed her Right hand glove. It was observed Staff G went back to Station #2 the station and continued to clean the station with a new chemical/sanitizing wipe. At 10:00 a.m. an interview Staff G, she revealed she was cleaning the machine after patient use and in doing so she uses a chemical/sanitizing wipe. She was asked what the process is for doffing and changing gloves. Staff G revealed when she leaves the station and doffs gloves, she is to then either sanitize and or hand wash her hands, prior to donning new gloves. Staff G could not remember if she did that or not when she left the station to go to an area to doff and re glove. Staff G also could not remember if she changed one glove or two, but she did remark that she should be washing her hands after each glove removing and prior to re gloving. She did confirm that after she changed the one glove, she did go back to the station to continue wiping with the chemical/sanitizer wipe. Staff G did confirm she had been trained and inserviced related to proper hand hygiene and when to wash hands during care and services and also when changing gloves after touching dirty/soiled areas. On 8/27/2024 at 12:16 p.m. an interview with the Director of Operations (DO), confirmed she had seen the staff electronic telephone device on a clean table, next to clean supplies and revealed that she has gone over this with staff many times that they are supposed to keep their phones in their pockets or in bags. She revealed that electronic devices are not supposed to be out in the open and there is no way to know when the devices were sanitized. The DO also expressed she has trained and inserviced staff repeatedly in all clinics to include making sure the Naturalyte liquid jugs are always capped and closed when in use. She confirmed that the jugs should not be left open to the air/elements and need to be capped to prevent any debris getting in the jug as well as getting into the tubing to the machine.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 34768 Based on interview and record review the facility failed to achieve and sustain the prescribed dose of dialysis to meet the prescribed Dialysate Flow Rate (DFR) for 4 patients (#1, #2, #11, #12), and Blood Flow Rate (BFR) for 5 of 12 sampled patients (#1, #2, #5, #7, #10). Findings included: 1. Review of Patient #1’s physician orders revealed a DFR of 800 ml (milliliter)/ min (minute) and a BFR of 450 ml / min. On 06/21/2024 the DFR was documented at 500 ml/min for 6 of 6 assessments. On 06/21/2024 the BFR was documented at 400 ml/min for 6 of 6 assessments. On 06/28/2024 the BFR was documented at 300 ml/min for 3 of 8 assessments. On 07/05/2024 the BFR was documented at 350 ml/min for 4 of 5 assessments. The record lacked documentation for the reason for the BFR and DFR not following orders. 2. Review of Patient #2’s physician orders revealed a BFR of 400 ml/min and a DFR of 800 ml/min. On 08/19/2024 the BFR was documented at 450 ml/min for 8 of 8 assessments. On 08/19/2024 the DFR was documented at 500 ml/min for 5 of the 8 assessments. On 08/21/2024 the BFR was documented at 350 ml/min for 8 of 8 assessments. On 08/23/2024 the BFR was documented at 450 ml/min for 1 of the 8 assessments and at 350 ml/min for 7 of the 8 assessments. The record lacked documentation for the reason for the BFR and DFR not following orders. 3. Review of Patient #12’s physician orders revealed a BFR of 450 ml/min. On 08/19/2024 the BFR was documented at 500 ml/min for 3 of 9 assessments and at 400 ml/min for 5 of 9 assessments. On 08/23/2024 the BFR was documented at 400 ml/min for 3 of 8 assessments. The record lacked documentation for the reason for the BFR not following orders. 20536 4. Review of Patient #5’s physician’s order sheet, last updated on 5/8/2024, revealed orders to include but not limited to: BFR levels = 500, and DFR levels = 800 ml/min. A review of the last six treatment visit reports dating 8/12/2024, 8/14/2024, 8/16/2024, 8/19/2024, 8/21/2024, and 8/23/2024 revealed the following: Visit dated 8/23/2024 11:14 a.m. revealed BFR was 250, which was 250 lower than ordered 500. Visit dated 8/19/2024 11:48 a.m. revealed BFR was 300, which was 200 lower than ordered 500. Visit dated 8/12/2024 11:41 a.m. revealed BFR was 300, which was 200 lower than ordered 500. There were no nurse progress notes or MD progress notes that indicated the reason this level was out of the ordered range. 5. Review of Patient #7’s physician’s order sheet, last updated on 8/13/2024, revealed orders to include but not limited to: BFR levels = 450, and DFR levels = 800 ml/min. A review of the last six treatment visit reports dating 8/13/2024, 8/15/2024, 8/17/2024, 8/20/2024, 8/22/2024, and 8/24/2024 revealed the following: Visit dated 8/20/2024 11:11 a.m. revealed BFR was 300, which was 250 lower than ordered 450. Visit dated 8/20/2024 11:32 a.m. revealed BFR was 300, which was 250 lower than ordered 450. Visit dated 8/20/2024 11:47 a.m. revealed BFR was 300, which was 250 lower than ordered 450. Visit dated 8/20/2024 13:02 a.m. revealed BFR was 300, which was 250 lower than ordered 450. Visit dated 8/20/2024 11:32 a.m. revealed BFR was 300, which was 250 lower than ordered 450. Visit dated 8/20/2024 11:35 a.m. revealed BFR was 300, which was 250 lower than ordered 450. Visit dated 8/20/2024 14:04 a.m. revealed BFR was 300, which was 250 lower than ordered 450. Visit dated 8/20/2024 14:34 a.m. revealed BFR was 300, which was 250 lower than ordered 450. Visit dated 8/20/2024 15:00 a.m. revealed BFR was 300, which was 250 lower than ordered 450. There were no nurse progress notes or MD progress notes that indicated the reason this level was out of the ordered range. 6. Review of Patient #10’s physician’s order sheet, last updated on 3/21/2024, revealed orders to include but not limited to: BFR levels = 450, and DFR levels = 800 ml/min. A review of the last six treatment visit reports dating 8/16/24, 8/17/24, 8/19/24, 8/21/24, 8/23/24, 8/26/24, revealed the following: Visit dated 8/24/2024 10:35 a.m. revealed BFR was 200, which was 250 lower than the ordered 450. Visit dated 8/17/2024 11:20 a.m. revealed BFR was 200, which was 250 lower than the ordered 450. There were no nurse progress notes or MD progress notes that indicated the reason this level was out of the ordered range. 7. Review of Patient #11’s physician’s order sheet, last updated on 6/26/2024, revealed orders to include but not limited to: BFR levels = 350, and DFR levels = 800 ml/min. A review of the last six treatment visit reports dating 8/13/24, 8/15/24, 8/17/24, 8/20/24, 8/22/24, 8/24/24, revealed the following: Visit 8/26/2024 12:00 p.m. revealed DFR at 100, which was 700 lower than the ordered 800. There were no nurse progress notes or MD progress notes that indicated the reason this level was out of the ordered range. On 8/27/2024 at 1:00 p.m., an interview with the facility’s Director of Operations (DO), confirmed the above BFR and DFR levels regarding patients #5, #7, #10, and #11. She revealed there were no notes that reflected staff caught these out of range BFR and DFR levels and there were no notes that indicated what was done for each of those out of range levels.”