Usrc Bethesda Dialysis

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 36839 Based on observations and a review of the facility’s policies and procedures, the governing body failed to ensure that all emergency supplies and safety equipment in the facility are regularly monitored to ensure that they are complete, easily accessible, functional and free of defects. This failure placed the patients and staff at potential risk of harm, injury, or even death. Findings included: 1. Fire extinguishers shall be checked monthly to verify it is: (a) Fully charged, (b) Safety seals are not broken or missing, (c) There is no evidence of physical damage, corrosion, leakage, or clogged nozzle, (d) Kept in its designated place at all times except during use, (e) There are no obstructions to access or visibility, (f) The fire extinguisher inspection shall be documented on the inspection tag or appropriate log. During inspection of the fire extinguishers in the dialysis treatment room on 8/6/2024, four fire extinguishers located within the facility had no record showing that they had been checked on February and March 2024. These fire extinguishers were located (1) At the patients’ waiting room entrance, (2) by the emergency exit adjacent to the dirty sink and dialysis station #3, (3) Across the medical waste room, and (4) In the storage/biomed room. These findings were verified with the facility administrator and clinical specialist during the exit conference on 8/8/2024.”

“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: 36839 Based on observation and interview with the facility staff, the governing body failed to ensure that all clinical staff were aware where the key to the patients’ restroom was being kept. This failure could result in patient harm, or even death, should an emergent need arise while the patient is in the restroom. Findings included: Awareness of the location of essential items, including bathroom keys, by all staff members responsible in the care of the patients in a dialysis unit is crucial in order to ensure that staff can assist their patients promptly, especially in cases of a medical emergency. Delays in accessing the bathroom can exacerbate certain medical conditions. During clinical staff interview on 8/6/2024, PCT #7 was asked where the key to the patients’ restroom in the dialysis treatment room was kept to which the PCT responded, “I do not know.” When asked what to do in case of an emergency and the patient is unable to unlock the door from inside, the PCT responded, “It has never occurred since I started working here.” This was verified with the facility administrator at the end of the survey day on 8/6/2024 and again discussed during the exit conference on 8/8/2024.”

“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: 36839 Based on observations in the clinical treatment room, the governing body failed to maintain the facility in a manner that ensured the integrity of all surfaces were kept intact, clean and free of damage. This failure increased the risk of ineffective cleaning, and the potential for unseen microbial growth and safety issues. Findings included: A dialysis facility must be meticulously maintained to ensure it remains free from defects and hazards, thereby safeguarding both the safety and functionality of the environment. This involves ensuring the integrity of all surfaces within the facility, which must be kept intact, clean, and undamaged which is crucial for allowing thorough cleaning and disinfection processes that is essential in preventing the spread and growth of microbial organisms. During observations on the clinical treatment floor on 8/6/2024, the following were noted: 1. The flooring of the cabinet in front of station #2 labeled as storage for 1K and 3K acid containers is surrounded with white-grayish substances, and the door hinges were covered with brown-black sticky substances. 2. The base of the faucet of the dirty sink near station #3 was surrounded with black substances. These findings were verified with the facility administrator at the end of the day on 8/6/2024 and again discussed during the exit conference on 8/8/2024.”

“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: 36839 Based on observations, the facility’s administration failed to ensure that all supplies essential to the delivery of appropriate dialysis treatment were maintained in a manner that provided for patient safety. This failure placed the affected patients at potential risk of harm. Findings included: When medications and supplies have reached their expiration date, they should be disposed of promptly. Healthcare providers should remove expired medications and supplies as quickly as possible to help reduce the chances that others accidentally receive or intentionally misuse them. During inspection of medications and supplies in the clinical treatment room on 8/6/2024, the following were noted: 1. 22 sets of 15-gauge fistula needles with various expiration dates ranging from 3/31/2023 to 11/30/2023 were found in the supply drawer across station #3. 2. One bottle of hydrogen peroxide with an expiration date of 3/2023 was found in the emergency evacuation box. 3. One bottle of Calcitriol 0.5 mg capsules with an expiration date of 6/2024 was found in the medication drawer. These findings were verified with the charge nurse on 8/6/2024.”

“PR-CAN HAVE ADVANCE DIR,TOLD FAC AD P&P CFR(s): 494.70(a)(6) The patient has the right to- (6) Be informed about his or her right to execute advance directives, and the facility ’ s policy regarding advance directives; This Standard is not met as evidenced by: 36839 Based on medical record review, the facility administrator and medical director failed to ensure that all of the facility’s patients had a completed Medical Orders for Life-Sustaining Treatment Form (MOLST) in their patient records. This failure denied the patient’s rights to formulate treatment decisions that served their end-of-life needs. Patients: #4, #5, and #6 Maryland Code 10.01.21.04B(4)E(1)(2)(3) mandates that, starting July 1, 2013, kidney dialysis centers must accept, update, and complete the Medical Orders for Life-Sustaining Treatment (MOLST) form during patient admission. When completing or updating the MOLST form, health care facilities must offer patients or authorized decision makers the opportunity to participate. If declined, the facility must document the refusal in the medical record, including the date, time, participants, and a summary of the discussion. Patients are to be informed that the MOLST form becomes part of the medical record, accessible through standard record procedures. A review of the medical records revealed that the following sampled patients did not have a completed MOLST form in their charts: 1. Patient #4 was admitted to the facility on 6/25/2024. 2. Patient #5 was admitted to the facility on 4/22/2024. 3. Patient #6 was admitted to the facility on 5/20/2024. These findings were confirmed by the clinical specialist upon review of the medical records.”