Liberty Dialysis Hawaii - Hawaii Salt Lake

“IC-SUPPLY CART DISTANT/NO SUPPLIES IN POCKETS CFR(s): 494.30(a)(1)(i) If a common supply cart is used to store clean supplies in the patient treatment area, this cart should remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. Such carts should not be moved between stations to distribute supplies. Do not carry medication vials, syringes, alcohol swabs or supplies in pockets. This Standard is not met as evidenced by: 51868 Based on observations, staff interviews and facility policy review, the facility failed to store clean supplies in a designated area at a sufficient distance from the patient stations to avoid contamination with blood by keeping and carrying thermometer in pockets. This deficient practice places the facility at risk for transmitting blood borne pathogens and infections and has the potential to negatively impact all 125 patients receiving in-center hemodialysis treatments. Findings Include: On 08/20/25, at 11:36 AM, observation was done. Patient Care Technician (PCT) 10 was observed discontinuing dialysis treatment for Patient (P) 18 at station 15. After PCT10 obtained P18’s temperature using the infrared (IR) thermometer, she proceeded to put IR thermometer inside her pocket. After PCT10 was done assisting P18, she then proceeded to station 16 and checked P17’s temperature using the same IR thermometer that she kept in her pocket. On 08/20/25 at 11:40 AM, an interview was conducted with Charge Nurse (CN) 2. CN2 confirmed that any equipment brought into the dialysis station needs to be disinfected and wiped down with disinfectant wipes and then returned to the designated area. Review of the facility’s policy titled, “Storage of Supplies,” published date 04/05/2021, Version 2, stated, “. . . All supplies must be stored in a clean, well lit, and climate-controlled environment. . .””

“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: 51868 Based on observation, interview and record review, the facility failed to maintain a safe environment by storing all clean supplies off the floor. Failure to store and handle all clean supplies properly had the potential to negatively impact all in-center patients receiving dialysis treatment at this facility. Findings Include: On 08/20/25 at 8:35 AM, during flash tour of the facility’s storage room, concurrent observation and interview was done with Biomed Technician (BMT) 7, observed four boxes of clean supplies on the floor. BMT7 said that clean supplies should not be on the floor. On 08/20/25 at 10:36 AM, an interview was done with the Clinical Manager (Mgr) 2. Mgr2 confirmed clean supplies should be stored off the floor. Review of the facility’s policy titled, “Storage of Supplies,” published date 04/05/2021, Version 2, stated, “. . . All clean or sterile supplies, except drums of concentrate, must be stored off the floor. . .””

“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: 39754 Based on observation, staff interview and review of policy, the facility failed to discard six expired fistula needles and three expired recirculation connectors/caps from the one Emergency Cart reviewed. As a result of this deficiency, there was increased risk for medical complications. Findings include: During observation of the Emergency Cart, on 08/20/25 at 11:00 AM, the following supplies were noted to be expired: six packages of safety fistula needles with an expiration date of 05/31/25 and three packages of recirculation connectors/caps with expiration dates of 02/29/25 and 03/31/25. Staff interview on 08/20/25 at 11:25 AM, Charge Nurse (CN) 2 acknowledged that the expired supplies, previously listed, should have been discarded. CN2 also revealed that those items were not even on the Emergency Cart inventory list and immediately removed them to be discarded. Review of facility policy on Emergency Medications, Equipment and Supplies read; Purpose, the purpose of this policy is to provide guidelines for staff when determining and maintaining emergency equipment and supplies ... Definitions, emergency cart, sometimes called “crash cart” contains emergency equipment and medications for medical emergencies such as a cardiac arrest ... Emergency cart must be locked when not in use, checked monthly or after use for contents, expirations dates, cleanliness and proper functioning of all equipment ... An itemized log must be kept indicating the contents and expiration dates of contents ...”

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 39754 Based on observation, staff interview and review of policy, the facility did not display the correct State Agency telephone number on all the Patient Rights forms. As a result of this deficiency, the patient’s right to have the State Agency complaint telephone number prominently displayed was not followed. Findings include: During observation of the Patient Rights forms on 08/21/25 at 09:00 AM, the current State Agency telephone number was wrong. The number only contained nine digits instead of the ten. Review of all the Patient Rights forms (printed for patients) showed the same wrong telephone number. Staff interview on 08/21/25 at 09:10 AM, Charge Nurse (CN) 2 acknowledged that the State Agency telephone number was wrong. CN2 removed all the Patient Right forms (printed for patients) and said they would make the necessary corrections.”

“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: 51868 Based on observation, interview and record review, the facility failed to ensure all direct patient care staff who treat patients in the facility follow the policy and procedure on medication preparation and administration. This deficient practice has the potential for the medication to be obtained and used illegally. Findings Include: On 08/20/25 at 11:15 AM, observed one out of six unlocked Patient Care Technician (PCT) heparin boxes on the nurse’s station. Surveyor opened lid to the unlocked heparin box and observed two vials of heparin that was left in the unlocked heparin box. One heparin vial was sealed, and the other one was opened and half full. During this observation an interview was done with PCT9. Inquired if the heparin box is to remain locked when not in use and PCT9 confirmed it is to be locked when not in use. During an interview with Charge Nurse (CN) 2 she acknowledged all medication lock boxes are to be locked and secured. The Clinical Manager (MGR) 2 confirmed in an interview on 08/20/25 at 01:30 PM, that all medication lock boxes be locked and secured at all times. Review of facility policy “Medication Preparation and Administration,” Published date 07/07/25, Version 02, states: “. . . All medications will be in a locked cabinet except when in use . . .””