Usrc Hayden Dialysis

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 51906 Based on observations and staff interviews, it was determined the facility failed to maintain a sanitary environment. This had the potential to affect all patients dialyzing in the facility due to lack of maintenance and cleanliness of the cabinets and other common areas on the treatment floor in the dialysis center. Findings include: Observations were conducted on the treatment floor on 5/07/25 beginning at 12:30 PM. The following issues were noted. 1. On 5/07/25 at 12:45 PM blood was observed on the floor of the center by Station #13 while a patient was receiving dialysis. Patient completed treatment and left. Station #13 was cleaned by a PCT, blood remained on floor. The blood on the floor was shown to PCT and they acknowledged that there was dried blood on the floor and cleaned the blood off the floor. 2. On 5/07/25 at 12:50 PM a thick layer of dark dusty residue was observed under several sinks in the center. The above observations were reviewed with the FA on 5/07/25 beginning at 2:15 PM and she confirmed that there should not have been blood on the floor and the residue under the sinks should have been cleaned. The facility failed to maintain a sanitary environment.”

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 51906 Based on record review and staff interview, it was determined the facility failed to ensure services were provided in accordance with the POC for 2 of 9 ICHD patients (Patient #1 and #9) whose records were reviewed. Not meeting the prescribed BFR had the potential for inadequate dialysis treatment. Findings include: 1. Patient #1 was an 85 year old female who received ICHD. Her dialysis prescription ordered a BFR of 350. Thirteen treatment sheets were reviewed from 4/07/25 to 5/05/25. The treatment sheets from 4/17/25 documented the BFR was started at 300 at 2:38 PM. At 4:01 PM the BFR was documented to be 320 and continued at 320 through the end of treatment at 5:34 PM. There was no documentation as to why the BFR did not meet the prescribed rate. The treatment sheets from 5/02/25 documented the BFR was started at 350 at 3:32 PM. At 4:06 PM the BFR was documented to be 300 and continued at 300 through the end of treatment at 6:30 PM. There was no documentation as to why the BFR did not meet the prescribed rate. 2. Patient #2 was a 72 year old female who received ICHD. Her dialysis prescription ordered a BFR of 400. Thirteen treatment sheets were reviewed from 4/05/25 to 5/06/25. The treatment sheets from 4/26/25 documented the BFR was started at 450 at 8:08 AM. At 8:32 AM the BFR was documented to be 400 and continued to be 400 through the end of treatment at 11:46 AM. There was no documentation as to why the BFR was not at the prescribed rate. The CS was interviewed on 5/08/2025 beginning at 2:24 PM and Patient #1 and #9’s treatment sheets were reviewed in her presence. She agreed the BFR did not follow Patient #1’s and Patient #9’s BFR prescription for the above treatments. Additionally, she stated that she would expect to see a note in the treatment record as to why the BFR was not met. The facility failed to ensure patients received their prescribed treatment as outlined in their plan of care.”