Davita Chelsea Dialysis

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 36887 Based on observation, interview, and record review, the facility failed to clean all surfaces of the treatment station between each patient in 2 of 2 observations and failed to wait to clean the dialysis machine until the patient left the treatment station in 1 of 2 observations resulting in the potential to spread infectious agents. Findings include: On 4/10/2024 at 1048, Staff I was observed cleaning the dialysis machine in Station #7 with a haphazard wiping pattern that did not include all surfaces of the machine being wiped with the bleach cloth. Additionally, it was noted that the patient was still in Station #7 while Staff I was cleaning the machine. Upon the patient walking away from the station on 4/10/2024 at 1049, Staff I began cleaning the dialysis chair with the similar haphazard wiping approach. Staff I failed to clean the backrest of the chair, failed to clean all surfaces of the wings of the chair, and failed to clean the cord for the blood pressure cuff before draping the cord and cuff across the top of the dialysis machine. Additionally, the back counter in the treatment station and the television/arm was not cleaned. On 4/10/2024 at 1110, Staff C was queried as to if it were okay to start cleaning the patient station before the patient left the station wo which she stated, “No.” On 4/11/2024 at 0921, Staff H was observed cleaning Station #6. Staff H placed a large blood pressure cuff on the still uncleaned chairside table, cleaned one side, then turned it over, laid it back on the table, and cleaned the other side before picking it up and placing it in the basket on the side of the still uncleaned dialysis machine. She cleaned a smaller cuff still attached to the cord in the same manner, cleaned the cord, and then placed the cord on the still uncleaned intravenous (IV) pole on the dialysis machine with the cuff touching the dirty machine. Staff H also failed to clean the backrest of the dialysis chair. Facility policy #1-05-01 titled “Infection Control for Dialysis Facilities” last revised 4/2023 states, “At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, bloood pressure cuffs) and frequently contacted b y healthcare personnell (e.g., control panel; top, front and sides of dialysis machine; touchscreens; countertops)...Dialysis station must be completely vacated by the previous patient before teammates can begin to bring disinfection supplies to the station, clean or disinfect the station and set up for the next patient.””

“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: 29955 Based on observation and interview, the facility failed to store clean patient care items in a clean storage area, failed to maintain a clean and sanitary water room, and failed to properly store chemicals, paint, and oxygen tanks resulting in the potential for the spread of infection and/or harmful contaminants to all 26 patients receiving dialysis treatment at the facility. Findings include: On 4/10/2024 at 1120 during inspection of the soiled utility room it was revealed privacy screens, an IV pump, and a blood pressure device was kept in the soiled utility room which also housed a hopper (a large waste receptacle) that had stagnant water with a pungent odor. The hopper was found to have a brown substance growing in the water in the bowl of the hopper. On 4/10/2024 at 1130 Staff A was asked if clean patient care items should be stored in the soiled utility. Staff A responded, “I’ll get those items moved immediately.” Staff A stated she was unaware of the odors being emitted from the hopper and stated, “I will have the hopper removed immediately...we do not utilize it.” 38905 On 4/11/24 at 0910, observation of the water room found accumulation of salt and debris behind the storage tanks of acid. When asked about the area the acid tanks are stored in, Staff F stated that it should be attended to, but he has a hard time getting back there to clean. On 4/11/24 at 0918, observation of the housekeeping closet found the top shelf had cleaning chemicals intermingled with clean and sanitary paper towel and toilet paper. On 4/11/24, at 0925, observation of the supply room found three upright oxygen tanks with no support or secure method to prevent them from falling. An interview with Staff F found that they are usually not stored like that and that. 36887 On 4/10/2024 at 1010, the clean storage room was entered and found to have nine paint cans present on the lower supply shelf, some with rusted lids and some with dried paint on the outside of the can. This finding was confirmed by Staff A at the time of discovery who stated the cans were kept for “touch-ups” as needed. It was noted there were other clean supplies present nearby on the same shelf. Facility policy #8-04-01 titled “Physical Environment” last revised 4/2018 states, “The dialysis facility will be designed, constructed, equipped, and maintained to provide dialysis patients, teammates, and the public a safe, functional, and comfortable treatment environment... Supplies are stored as to minimize deterioration, contamination or breakage.” Facility policy #1-05-01 titled “Infection Control for Dialysis Facilities” last revised 4/2023 states, “Clean areas should be clearly designated for the preparation, handling, and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled.””

“PR-INFORMED OF EXTERNAL GRIEVANCE PROCESSES CFR(s): 494.70(a)(15) The patient has the right to- (15) Be informed of external grievance mechanisms and processes, including how to contact the ESRD Network and the State survey agency; This Standard is not met as evidenced by: 29955 Based on document review and interview the facility failed to have the correct information provided for patients to file an external grievance resulting in denying all 26 patients the right to file a grievance with external agencies. Findings include: On 4/10/2024 at 1400 during observation of the patient waiting area a sheet titled “Grievance” was posted with an incorrect phone number for the state agency. The document listed contact for the state agency as: “State of Michigan: 1-517-373-9196.” On 4/10/2024 at 1420 during an interview with Staff A, the facility administrator, it was asked if she knew the information was incorrect. Staff A stated, “No, I did not know it was incorrect...we will have that fixed immediately.””