Fmc - Rcg Thomasville

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 50244 Based on observation, a review of Centers for Disease Control and Prevention (CDC) guidelines and staff interviews, it was determined that the Infection Control Committee failed to ensure that warm water was available to facilitate hand washing; and that 16 of 16 dialysis wall boxes (Frames recessed into the walls at each hemodialysis station that contain connections for the dialysis machine to receive acid and base concentrates and treated water, and dispose of water products.) at Stations 1-16 were cleaned and disinfected on a daily basis to decrease risk of patient infection. This failure had the potential for microbial growth which can be transferred to 50 in-center hemodialysis patients who were dialyzing at this facility. Findings include: Cross References: V114 - Failure of the facility to ensure that four of four sinks in the Patient Treatment Room, one of one sink in the Patient Restroom and two of two sinks in the Staff Restrooms had warm water available to facilitate hand washing. V122 - Failure of the facility to ensure that staff cleaned and disinfected the dialysis wall boxes at least daily to prevent transmission of dangerous pathogens.”

“CFC-PHYSICAL ENVIRONMENT CFR(s): 494.60 This Condition is not met as evidenced by: 50244 Based on observation and staff interviews, it was determined that the facility failed to ensure that all equipment and the building in which dialysis services were furnished were sanitary and maintained free from damage and defects, to ensure the safety of all patients and staff. The failure to maintain the integrity of all surfaces, hindered effective cleaning and disinfection of surfaces thus, had the potential for microbial growth and could lead to transmission of bloodborne pathogens. This deficient practice could negatively affect the health and safety of all staff and the 50 in-center hemodialysis patients who were dialyzing at this facility. Findings include: Cross References: V401 - Failure of the facility to provide dialysis patients and staff a safe, functional, and comfortable treatment environment. V403 - Failure of the facility to maintain water treatment equipment to ensure the safety of the patients and staff.”

“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: 50244 Based on observation and staff interview, it was determined that the facility failed to ensure that four of four sinks in the Patient Treatment Room, one of one sink in the Patient Restroom and two of two sinks in the Staff Restrooms had warm water available, to encourage staff to wash their hands according to the Centers for Disease Control (CDC) recommendations; and that warm water was available for patients to wash their access sites prior to treatment and their hands after treatment. This failure could negatively affect the health and safety of 50 patients who were receiving dialysis treatment at this facility. Findings were: During a tour of the facility on 2/5/24 at 8:30 a.m., the following was revealed: - There were four sinks in the Patient Treatment Room, one sink in Patient Restroom and two sinks in the Staff Restrooms. - All sinks did not have warm water after running each faucet for three to five minutes at a time. The Facility Administrator was notified and confirmed the above findings on 2/5/24 at 9:30 a.m.”

“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: 50244 Based on observation, a review of the Centers for Disease Control and Prevention (CDC) guidelines, and staff interview, it was determined that the Infection Control Committee failed to ensure that 16 of 16 dialysis wall boxes (Frames recessed into the walls at each hemodialysis station that contain connections for the dialysis machine to receive acid and base concentrates and treated water, and dispose of water products.) at Stations 1-16 were cleaned and disinfected on a daily basis to decrease risk of patient infection. This failure had the potential for microbial growth which can be transferred to 50 in-center hemodialysis patients who were dialyzing at this facility. Findings were: During observation on 2/5/24 - 2/6/24 between 8:00 a.m. and 2:00 p.m., the following was observed: - The dialysis wall boxes were visibly dirty and had rust-colored stains and accumulated dried white and brown substances on the surfaces of the wall boxes at Stations 1 - 16 which had the potential for microbial growth. A review of the CDC Dialysis Safety: Dialysis Wall Boxes and Drains last reviewed on 10/25/19 stated: There are several infection prevention and control issues unique to wall boxes. They can become easily contaminated with microorganisms, which can subsequently be transferred to dialysis patients ... Thus, wall boxes need to be cleaned, disinfected, and properly maintained to decrease risk of patient infections. Wall box surfaces should be disinfected at least daily; cleaning and disinfection might be needed more frequently (e.g., when visibly dirty). The Facility Administrator was notified and confirmed the above findings on 2/6/24 at approximately 2:00 p.m.”

“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: 50244 Based on observation and staff interviews, it was determined that the facility failed to ensure that all equipment and the building in which dialysis services were furnished were sanitary and maintained free from damage and defects, to ensure the safety of all patients and staff. The failure to maintain the integrity of all surfaces, could hinder effective cleaning and disinfection of surfaces and could promote microbial growth. This deficient practice had the potential to negatively affect the health and safety of all staff and 50 in-center hemodialysis patients who were receiving dialysis services at this facility. Findings include: During observation on 2/5/24 - 2/6/24 between 8:00 a.m. and 2:00 p.m., the following was observed: In the Patient Treatment Room: - The floor tiles and baseboards throughout the treatment room was in general disrepair. - The floor tiles were stained and cracked in several areas. - The brown baseboards had white stains and scraped marks. - The walls throughout the facility had streaks in areas that have had contacts with liquids. This defects ranged from small areas of splashed discoloration to long streaks that marked larger sections of the walls. - The wall behind Station 12 had a bulging drywall that measured 14 inches high by six inches wide. This area had peeled paint and several holes in the wall. - The walls above the chase counter behind Stations 9 and 10 were damaged with bubbles extending to three inches above the chase counter. - The Nurses Station walls had several large black scraped areas. - The corner of the Nurses Station counter wall near the baseboard, across from Station 14 was damaged that exposed the plaster material in the wall. - The walls adjacent to some of the sinks were devoid of paint in some areas. - The frame of the entry door to the treatment area was missing large sections of white paint. - The paint above the chase counter (used by some patients to store personal belongings during dialysis) behind multiple Stations, were cracked that could result for paint chips to fall off the surface. - The finish was peeling on the chase counter behind multiple stations. - The chase counter hinges had rust-colored substance on the chase counter behind several stations. - The fixtures on the sinks were covered with hard white substance/sediments at the bases and around the edges of the sinks. - The edges of some sinks had rust colored stains. - The sink counters were worn off. - The window blinds on six of six windows were stained and had bent slats. - The windowsills behind Stations 1, 2, 3, 10, 11, and 13 had a layer of dust. In the Water treatment Room: - The condition of the floor was predominantly unsanitary. - The floor underneath the booster pump and pre-filter housing had rust-colored liquid, crusted cream colored sediments, and had a large quantity of white and brown debris on the left corner of the floor next to the wall. - There was rust- colored liquid on the floor next to the Reverse Osmosis machine. - The concrete floor was damaged/cracked in multiple locations at junction of the baseboard and floor; and had a large area of damaged/cracked concrete leading into the Biomedical Technician Room. This could hinder effective cleaning and disinfection thus providing a potential for microbial growth. - The floor around the Acid Mixing Tank and the Acid Holding tank were covered with white crystalized substance. During an interview with the Facility Administrator and Director of Operations on 2/6/24 at approximately 12:00 p.m., it was revealed that they were already aware of the above findings.”

“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: 50244 Based on observation and staff interview, it was determined that the facility failed to ensure that the water treatment equipment was maintained to ensure the safety of all staff and 50 in-center hemodialysis patients who were dialyzing at this facility. This deficient practice was observed in one of one Water Treatment Room. Findings include: During observation on 2/5/24 at 2:00 p.m., the following was observed: In the Water Treatment Room: - The base and the two fittings/pipe connectors at the bottom of the booster pump were covered with rust-colored substance. - The booster pump, pre-filter housing, all fittings/pipe connectors, and 85 percent of all connection pipes and tubes were covered with dried/crusted white sediments and white crystalized substance. - The floor underneath the booster pump and pre-filter housing had rust-colored liquid/water. - The blue frame at the base of the Reverse Osmosis machine had areas of peeled paint that exposed rust-colored substance. Rust- colored liquid/water was also present on the floor. During an interview with the Facility Administrator and Director of Operations on 2/6/24 at approximately 12:00 p.m., it was revealed that they were already aware of the above findings.”

“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: 50244 Based on a review of medical records, staff interview, and a review of policy and procedure, it was determined that the interdisciplinary team (IDT) failed to implement the patients’ plan of care to effectively manage patient outcomes for adequacy of dialysis [effectiveness of dialysis prescriptions to avoid symptoms of uremia (buildup of toxins in the blood)], for two of five sampled in-center hemodialysis patients (P#8 and P#18). The facility in-center hemodialysis census was 50. Findings were: A review of dialysis flowsheets from 1/15/14 - 2/2/24 revealed the following: P #8: - The prescribed Blood Flow Rate (BFR) for P#8 was 450 mL/min. - On 1/15/24, 1/18/24, 1/22/24, 1/29/24, 1/31/24, and 2/2/24, P#8 dialyzed with a BFR of 400 mL/min. - On 1/31/24, P#8 dialyzed with a BFR of 350 mL/min. - There was a lack of documented reasons for the decreased BFR delivered on 1/15/24, 1/18/24, 1/22/24, 1/29/24, 1/31/24, and on 2/2/24. - There was no documented evidence that a physician extender was notified when the prescribed BFR was not achieved. P #18: - The prescribed BFR for P#18 was 500 mL/min. - On 1/15/24, 1/19/24, and on 2/2/24, P#18 dialyzed with a BFR of 400 mL/min. - On 1/22/24, P#18 dialyzed with a BFR of 450 mL/min. - On 1/26/24, P#18 dialyzed with a BFR of 350 mL/min. - There was a lack of documented reason for the delivered BFR lower than 500 mL/min as ordered. - There was no documented evidence that a physician extender was notified when the prescribed BFR was not achieved. A review of Policy No. 45284 titled, “Patient Assessment and Monitoring” dated 5/1/23 stated: Follow the steps below for monitoring patient and machine parameters during treatment... Machine Parameters and Extracorporeal Circuit... Check machine settings and measurements: Check prescribed blood flow is being achieved or reason is documented in the medical record if unable to meet the prescribed blood flow. A review of Policy No. 47334 titled, “Unable to Achieve Prescribde Blood Flow Rate” dated 11/1/21 stated: Notify physician/extender if unable to achieve prescribed blood flow rate.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 50244 Based on observation and a review of facility policy, it was determined that the medical director failed to ensure that all Direct Patient Care Staff (DPCS) adhered to facility policy pertaining to vascular access care. This failure could lead to infection and loss of vascular access for eight of eight patients (P#1, P#3, P#4, P#5, P#12, P#13, P#15, and P#16) observed, during discontinuation of dialysis treatment. The facility census was 50. Findings were: During observations in the Patient Treatment Room on 2/5/24 and 2/6/24 between 10:00 a.m. and 11:30 a.m., the following was observed: - After dialysis, fistula needles were removed from P#1, P#3, P#4, P#5, P#12, P#13, P#15, and P#16’s cannulation (needle insertion) sites. - The sites were covered with gauze and tape, and pressure was applied to the cannulation sites. - After hemostasis (stopping of the flow of blood) was attained, the DPCS who were assigned to care for P#1, P#3, P#4, P#5, P#12, P#13, P#15, and P#16, did not discard the used gauze dressings but reinforced them with tape. - The DPCS did not apply new band-aid, adhesive dressing or gauze dressing over cannulation sites per facility policy, before the above mentioned patients were discharged. A review of facility policy titled, “Post Treatment Fistula Needle Removal” dated 07/06/21 state: Once hemostasis is achieved: Remove the gauze... Place band-aid, adhesive dressing or gauze dressing secured with clean tape.”