Rai - Rainbow Blvd - Westwood

“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: 50529 Based on observation and interview, the facility failed to ensure a “dirty” sink in the treatment area was in working order. Failure to ensure that sinks are in working order poses a risk for patients and/or staff to not be able to safely dispose of liquid waste from contaminated items, thus increasing the risk of spreading infectious pathogens for all 91 patients receiving care in this facility. Findings Include: Observation of the treatment floor showed a “dirty sink” that was inoperable on each day of the survey: 05/05/25, 05/06/25, 05/07/25, and 05/08/25. Observation on 05/06/25 at 9:08 AM, showed an inoperable “dirty sink” on the back side of the main nurse’s station. At the time, Staff I, Certified Clinical Hemodialysis Technician (CCHT), stated that the sink “comes on when it wants or doesn’t turn off”. Staff G, CCHT confirmed what Staff I had said about the sink. During an interview on 05/07/25 at 10:00 AM, Staff D, BioMed Technician (BMT), was asked about inoperable sink and he stated that the sink would be fixed at end of day when there were no patients on the treatment floor. During an interview on 05/07/25 at 3:00 PM, Staff A, Clinical Manager (CM), was asked about the non-functioning sink and if a work order was placed. Staff A stated that the facility was aware of the sink issue, but a work order was not submitted due to belief that BioMed was to repair after hours. Staff A voiced plans to follow up with Staff D (BMT) regarding the repair. During an interview on 05/07/25 at 3:03 PM, Staff B, Director of Operations, stated that a work order was submitted for repair of the inoperable sink.”

“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: 50529 Based on observation, policy review, and interview, the facility failed to ensure staff disinfected non-disposable medical equipment, specifically a stethoscope (instrument used to listen to heart/lung sounds) use between two patients. This deficient practice increased the risk for the spread of infectious pathogens (disease-causing microorganisms or infectious agents) for all 81 patients who received treatment in the facility. Findings Include: Review of a policy titled, “Cleaning and Disinfecting the Dialysis Station,” dated 09/05/23, showed “ ...After use, any non-disposable equipment and supplies brought into the dialysis station (ex. Stethoscope) must be disinfected with 1:100 bleach or EPA registered disinfectant before being removed from the dialysis station ...” Observation of the treatment floor on 05/06/25 from 10:57 AM until 11:00 AM, showed Staff E, Certified Clinical Hemodialysis Technician, (CCHT) failed to disinfect the stethoscope prior to use on a patient at Station 1. Staff E failed to disinfect the stethoscope after direct patient contact as required per facility policy and placed the stethoscope around his/her neck. Staff E continued this practice while moving between Stations 21 & 23 without disinfecting between uses. Observation on the treatment floor on 05/07/25 at 4:11 PM, showed Staff E, CCHT obtained a post treatment temperature with a thermometer that was pulled from his/her scrub pocket. After using the thermometer to obtain a patient’s temperature, Staff E placed the thermometer back in his/her pocket. During an interview on 05/07/25 at 8:49 AM, Staff E, CCHT, stated that stethoscopes and thermometers are to be disinfected with alcohol between uses and that reusable equipment should be disinfected after use to decrease risk for cross contamination. Staff E was not certain if there were facility policy or procedure regarding the disinfection of equipment. During an interview on 05/07/25 at 3:00 PM, Staff A, Clinical Manager, stated that the expectation of staff is to wipe stethoscopes and thermometers with bleach after use and after leaving the dialysis station. Staff A stated that non-disposable equipment should not be stored in pockets for use on the treatment floor. Staff A stated that either of these deficient practices could lead to potential infection and/or cross contamination.”

“PR-PRIVACY & CONFIDENTIALITY-RECORDS CFR(s): 494.70(a)(4) The patient has the right to- (4) Privacy and confidentiality in personal medical records; This Standard is not met as evidenced by: 50529 Based on observation, policy review, and interview, the facility failed to ensure confidentiality was maintained for patient medical records when computer screens were left unattended with patient specific information on display for 3 of 3 patients observed. This deficient practice places any patient receiving services at this facility at risk of having their personal health information exposed to unauthorized individuals and is a potential violation of their patient rights. Findings Include: Review of a policy titled, “HIPPA Privacy Policies and Procedures,” revised 04/16/24, showed, “[Facility Company] is committed to protecting the privacy of its patients ...These policies and procedures are designed to protect the confidentiality, security, and integrity of protected health information (PHI) ...Safeguarding PHI and Managing Uses ...Storage of Electronic PHE (ePHI). Access to ePHI will be limited to members of [Facility Company] workforces and business associates who require access to perform their duties ...” Review of a policy titled, “Patient Rights and Responsibilities,” dated 04/04/12, showed, “ ...The patient has the right to ...Privacy and confidentiality in personal medical records ...” Observation of the treatment floor on 05/06/25 at 9:03 AM, showed an unattended computer at the main nurses’ station that had patient health information on display. There were other patients, visitors, and non-clinical staff present at this time. Observation of the treatment floor on 05/06/25 at 10:35 AM, showed Staff I, Registered Nurse (RN), leave a computer with patient specific information left up on screen unattended at the main nurses’ station while she left to obtain medication in the medication room. During an interview on 05/06/25 at 11:38 AM, Staff I, RN, confirmed that patient health information was left up on a computer screen unattended at the main nurses’ station. Staff I wasn’t sure of policy but knew that this practice was not compliant. Staff I stated that he/she should have locked the screen prior to leaving the computer to protect patient privacy and confidentiality. During an interview on 05/07/25 at 3:00 PM, Staff A, Clinical Manager (CM), stated that it is the expectation of staff to protect patient health information by locking the computer screen or logging out of patient sensitive information prior to leaving a computer unattended.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 50529 Based on policy review, medical record review, and interview, the facility failed to ensure complete and accurate treatment records were recorded by a patient and maintained by the facility as required for 2 of 2 (Patient 2 and 8) sampled home hemodialysis (a medical treatment performed in the patient’s home that cleans the blood, removing waste products and excess fluid, when the kidneys are unable to do so) patients. This deficient practice has the potential to inhibit the ability to monitor treatment progress, identify potential issues, and increased risk of mortality which could negatively impact the health and well-being of the 10 patients that received home therapies services. Findings Include: Review of a policy titled, “Review and Documentation of Home Therapies Patient Health Data,” dated 05/01/23, showed “ ...The patient will create a treatment record for every dialysis treatment according to policy and regulatory requirements. Treatment data will be reviewed by the home therapies nurse in order to identify trends, determine if patients are following their treatment plans or having problems with their dialysis at home ...” Review of a policy titled, “Home Therapies Patient Treatment Record Keeping,” dated 09/05/23, showed, “ ...A record is required for each dialysis treatment. Patients and/or patient care partners will be taught to complete a daily record of home dialysis treatments and dialysis related home medication administration, educated regarding the importance of maintaining the records completely and accurately ...” Patient 2 Review of the medical record for Patient 2 showed the facility admitted the patient on 01/23/24 with a diagnosis of End Stage Renal Disease (ESRD). Review of the home hemodialysis treatment record from 04/15/25 - 05/02/25 provided by the facility showed the following: 1. 04/15/25- Patient 2 failed to provide documentation of post treatment (post- tx) weight, pre-treatment (pre-tx) sitting and standing blood pressures, post-tx sitting and standing blood pressures, and venous pressure at blood flow rate (BFR) of 200. There was no documentation that provided rationale for missing data collection information. 2. 04/17/25 - - Patient 2 failed to provide documentation of post -tx weight, pre-tx standing blood pressures, post-tx sitting and standing blood pressures, and venous pressure at BFR of 200. There was no documentation that provided rationale for missing data collection information. 3. 04/15/25 - Patient 2 failed to provide documentation of treatment duration, dialysate (the fluid used on the other side of membrane during dialysis to remove impurities that is measured in liters), UF (ultrafiltration [the process of removing fluid from a patient’s blood using a semipermeable membrane and pressure]), post-tx weight, post-tx sitting and standing blood pressures, and venous pressure at 200 BFR. There was no documentation that provided rationale for missing data collection information. 4. 04/18/25 - Patient 2 failed to provide documentation of weight, post-tx sitting and standing blood pressures, and venous pressure at 200 BFR. There was no documentation that provided rationale for missing data collection information. 5. 04/27/25 - Patient 2 failed to provide documentation of weight, post-tx sitting and standing blood pressures, and venous pressure at 200 BFR. There was no documentation that provided rationale for missing data collection information. Patient 8 Review of the medical record for Patient 8 revealed the facility admitted the patient on 05/02/19 with a diagnosis of ESRD. Review of the home hemodialysis treatment record from 04/14 -04/27/25 provided by the facility showed the following: 1. 04/18/25 - Patient 8 failed to provide documentation of weight, post-tx sitting and standing blood pressures, and venous pressure at 200 BFR. There was no documentation that provided rationale for missing data collection information. 2. 04/21/25 - Patient 8 failed to provide documentation of venous pressure at 200 BFR. There was no documentation that provided rationale for missing data collection information. 3. 04/23/25 - Patient 8 failed to provide documentation of venous pressure at 200 BFR. There was no documentation that provided rationale for missing data collection information. 4. 04/27/25 - Patient 8 failed to provide documentation of weight, post-tx sitting and standing blood pressures, and venous pressure at 200 BFR. There was no documentation that provided rationale for missing data collection information. During an interview on 05/08/25 at 7:10 AM with Staff N, Registered Nurse (RN), stated that home patients are expected to complete treatment records for every treatment thoroughly. The treatment records are reviewed by an RN at least monthly. Most patients’ treatment records are electronically submitted. Staff N confirmed that any blanks or discrepancies should have been reviewed and the patient re-educated as needed, and charted in the Ecube.”