Usrc South Georgia

“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: 49321 Based on observation and staff interviews, it was determined that the facility failed to ensure that there was a safe environment for all patients and staff, as evidenced by failure of the facility to ensure that one of one door in the Supply Room, was maintained to prevent entry of insects and vermin. This deficient practice had the potential to negatively impact the health and safety of 78 in-center hemodialysis patients who were under the care of this facility. Findings were: During a tour of the facility with RN AA on 4/8/24 at 2:28 p.m., the following was observed: In the Supply Room: - The metal door trim at the base of the door was rusted and separated from the door (approximately 37 inches long by 1/2 inch wide) that produced a gap between the door and the trim, and could allow insects and vermin to enter the building. In the Patient Treatment Room: - There was a large dead cockroach on the floor at Station (S) 1. - There was a small dead cockroach on the floor at S19 on the left side of the treatment chair. A review of facility records revealed a contract with an exterminator company for inspection and treatment of the facility once a month. The last visit date was made on March 2024. However, during staff and patient interviews, the following was revealed: - On 4/18/24 at 1:26 p.m., PCT AA stated she sees roaches all the time; they enter the facility under the back door. - During a telephonic interview with Patient #1 on 4/18/24 at 3:00 p.m., he stated that he saw a roach two weeks ago crawling near the Isolation Room. During an interview on 4/18/24 at 4:00 p.m., the Acting Facility Administrator and the Regional Operations Director both stated no one ever said anything about roaches.”

“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: 32734 Based on observation, staff interviews, and a review of records, it was determined that the facility failed to maintain a safe, functional, and comfortable evironment. This deficient practice had the potential to negatively impact the health and safety of 78 in-center hemodialysis patients who were under the care of this facility. During observation on 4/18/24 at 9:15 a.m., the following was revealed: In the Lobby: - The floor was dull and had accumulated dirt througout the floor. - The wall to the left (when you entered the Lobby) at eye level , had a three inches wide by four inches long hole in it. In the Patient Treatment Room: - The floor had accumulated dirt and blackish discolored tiles in an area (approximately three by three feet in diameter) near S 5, S6, S8, and S9. - There was grout and yellowish/white substance seeping through tiles in front of the chase wall at S14 and S15. - The chase wall panel near S1 had a hole (approximately two to three inches in circumference). - There were multiple white substance/stains splashed across the chase wall panel near S1 and S2. - The two windows in the isolation room had numerous white substance/residue splashed across the windows and on the outer ledges . - The countertop to dirty sink located at the back of the treatment floor, was eroded and separated from the edges of the cabinet. There were multiple white substance/residue splashed on the cabinet.. In the Supply Room: - The floor had accumulated dirt, and the floor finish was peeling away, eroded and discolored throughout the area. - Dirt and debris were observed on the baseboard and corners of the wall. - The silver colored cabinet (electrical panel) had numerous white subtance splashed on the cabinet and ledges. In the Water Treatment Room: - The floor was dull and had accumulated dirt throughout the floor. - The room adjacent to the Water Treatment Room which was used by the Biomed Technician, had shoe tracks across the floor which were embedded in black colored dirt. During an interview with Registered Nurse (RN) AA on 4/18/24 at 9:51 a.m., she stated “The floors were stripped about three months ago but not waxed. The facility changed cleaning companies and they don’t clean the building. This building has been dirty for about a year”. A review of the Facility Environmental/Safety Audits dated 1/30/24 and 3/26/24, showed the floors were “clean and dry”. A review of the QAPI meeting minutes from November 2023 through March 2024 showed no documentation of any facility environmental issues/concerns. During an interview on 4/18/24 at 4:30 p.m., the Regional Director acknowledged that there has been a problem with the cleanliness of the clinic.”

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 49321 Based on a review of personnel file and staff interview, it was determined that the facility failed to ensure that seven of seventeen full time, part time, and float employees [Registered Nurses (RN) AA, RN BB, Float RN CC, Patient Care Technicians (PCT) AA, PCT BB, PCT DD, and Float PCT EE], had current skill checklists to evaluate their ability to perform the duties that were assigned to them. This deficient practice had the potential to negatively impact the health and safety of 78 in-center hemodialysis patients who were under the care of this facility. Findings were: A review of the signed personnel file worksheet, that was filled out and submitted by the Acting Facility Administrator and a review of the following employee records, revealed the following: - RN AA, Float RN CC, PCT BB, PCT DD, Float PCT EE, did not have documented skills competency checklist. - RN BB and PCT AA had no documentation of current skills competency checklists. The last competency evaluation for RN BB and PCT AA were dated 1/12/23 and 2/27/23 respectively. During an interview with the Regional Director on 4/16/24 at 2:00 p.m., when asked about updated skills checklist, she stated “we’re in the process of getting skills checklist done”.”

“PQ-NURSE MANAGER-12 MO RN+6 MO DIALYSIS CFR(s): 494.140(b)(1) (1) Nurse manager. The facility must have a nurse manager responsible for nursing services in the facility who must- (i) Be a full time employee of the facility; (ii) Be a registered nurse; and (iii) Have at least 12 months of experience in clinical nursing, and an additional 6 months of experience in providing nursing care to patients on maintenance dialysis. This Standard is not met as evidenced by: 49321 Based on a review of facility records, observations, and staff interviews, it was determined that the facility failed to show evidence that a full-time Registered Nurse was in charge of nursing services that provided the supervision of licensed nurses and unlicensed personnel. This deficient practice had the potential to negatively impact the health and safety of 78 in-center hemodialysis patients who were under the care of this facility. Findings were: A review of RN BB’s personnel file revealed a signed job description for staff RN. There was a lack of training records, skills competency checklist, or other employee documents observed in her personnel file. A review of the facility’s Governing Body Meeting minutes dated 1/20/24, stated that RN BB was governed in as the Nurse in Charge of Nursing Services. During an interview with RN BB on 4/18/24 at 12:26 p.m., she stated, “I was unaware that I was the nurse in charge of nursing services. I never signed a job description for the position of a nurse in charge of nursing services and I work four days a week”. RN BB denied having time out from direct patient care to perform any administrative nursing duties and did not participate in any hiring or firing of staff or in any interdisciplinary team meetings (IDT) or governing body meetings. On 4/18/24 at 2:00 p.m., the Regional Director was informed that RN BB was unaware that she has been governed in as the nurse in charge of nursing services and was unaware that she was appointed to that position. The ROD shrugged her shoulders in response.”