Altru Dialysis Sat at Mercy Hosp

“Vertical Openings - Enclosure CFR(s): NFPA 101 Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box. This Standard is not met as evidenced by: 31889 The facility failed to protect vertical openings with self-closing doors. Observation determined the south stairway door on the lower level failed to self-close and latch into the door frame. Failure to provide protection at vertical openings increases the risk of injury or death due to fire. This deficiency affected one (1) of two (2) lower-level stairway doors.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 31889 The facility failed to provide smoke resistance protection with self-closing doors at Hazardous Area locations. Observation determined: 1- Numerous areas in the mechanical Room had unsealed openings to the corridor, above the corridor ceiling. 2- The Biohazard Room corridor door was not equipped with a self-closing device. Failure to protect hazardous areas increases the risk of injury or death due to fire. This deficiency affected two (2) of four (4) hazardous areas.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 31889 The facility failed to inspect and test the fire alarm system in accordance with NFPA 70 and NFPA 72. Record review determined the entire lower-level fire alarm devices were not inspected and tested during the most recent inspection. An outside vendor included newly installed devices and did not inspect and test existing devices on the lower level. Failure to inspect and test all devices within the fire alarm system increases the risk of injury or death due to fire. This deficiency affected numerous devices of the fire alarm system. The fire alarm system serves the entire building.”

“Electrical Systems - Receptacles CFR(s): NFPA 101 Electrical Systems - Receptacles Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover. If used in patient care room, ground-fault circuit interrupters (GFCI) are listed. 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 31889 The facility failed to provide Ground Fault Circuit Interrupter receptacles at wet locations. Observation determined four (4) electrical outlets in the Employee Breakroom within 6 feet of a sink were not GFCI protected. Failure to provide GFCI protected electrical outlets near wet locations increases the risk of injury or death due to fire. This deficiency affected one (1) of numerous wet locations in the facility.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 39211 Based on policy review, review of daily water log records, and staff interview, the facility failed to test the dialysis treatment water for free chlorine, chloramine, or total chlorine at least every four hours each patient treatment day for 1 of 27 treatment days (07/26/25) reviewed in July 2025, and failed to document the concentration level in parts per million (ppm) for five of the completed tests. Failure to test for free chlorine, chloramine, or total chlorine every four hours each day of patient treatments and record test strip results in ppm limited the facility’s ability to ensure safe dialysis treatment water. Findings include: Review of the policy “Chlorine/Chloramine Testing” occurred on 08/06/25. This policy, dated February 2025, stated, “. . . Total chlorine will be tested daily, initial testing prior to machine setup and, thereafter, at least every 4 hours during patient treatment times. . . . When performed correctly, the test will estimate total chlorine concentration between 0 and 3.0 ppm by comparing the color of the indicator pad to the color blocks on the bottle label. . . .” Review of the July 2025 daily water log/chlorine testing records occurred on 08/05/25 and showed the following: * Chlorine level tested on July 26th at 0413 (4:13 a.m.) and next at 1145 (11:45 a.m.) 7 hours and 32 minutes after the last test. * On July 23rd at 0500 (5:00 a.m.), 0853 (8:53 a.m.), 1241 (12:41 p.m.) on July 24th at 0412 (4:12 a.m.) and 0811 (8:11 a.m.) check marks placed in the section where chlorine ppm concentration level results were to be recorded. Staff failed to complete chlorine tests every four hours and failed to record chlorine test results in measured ppm. During an interview on 08/05/25 at 5:20 p.m., an administrative staff member (#2) confirmed staff had not checked the water system for chlorine every four hours on 07/26/25 and she expected staff to record the chlorine test results in ppm.”

“POC-MANAGE ANEMIA/H/H MEASURED Q MO CFR(s): 494.90(a)(4) The interdisciplinary team must provide the necessary care and services to achieve and sustain the clinically appropriate hemoglobin/hematocrit level. The patient’s hemoglobin/hematocrit must be measured at least monthly. The dialysis facility must conduct an evaluation of the patient’s anemia management needs. This Standard is not met as evidenced by: 19410 Based on record review, review of professional reference, and staff interview, the facility failed to provide the necessary care and services to sustain clinically appropriate hemoglobin/hematocrit levels (blood tests that measure the amount of protein in red blood cells) for 1 of 3 patients (Patient #5) receiving an iron medication during hemodialysis. Failure to administer medications used to treat anemia (low blood cell count) has the potential to result in worsening anemia and adverse effects. Findings include: Kozier & Erb’s “Fundamentals of Nursing, Concepts, Process and Practice,” 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, stated, . . . Nurses are expected to analyze procedures and medications ordered by the physician or primary care provider. . . . If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. . . .” Review of Resident #5’s medical record occurred on 08/06/25. Physician’s orders, dated 05/12/25, stated “Ferrlecit (medication to treat iron deficiency anemia) 62.5 mg [milligrams] every 2 weeks on Monday.” Review of Resident #5’s hemodialysis treatment documents showed staff failed to administer Ferrlecit on Monday, 07/21/25. During an interview on the afternoon of 08/06/25, an administrative nurse (#1) confirmed staff should administer medications as ordered.”