Carl T Curtis Health Ed Center Satellite Clinic

“IC-HBV-ISOLATION-MACHINES/EQUIP/SUPPLIES CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients To isolate HBsAg positive patients, ... dedicate machines, equipment, instruments, supplies, and medications that will not be used by HBV susceptible patients. This Standard is not met as evidenced by: 47269 Based on the review of facility policies and procedures, physical building audits, observations and staff interviews, the facility failed to maintain the isolation room by utilizing it for general patient supply storage. This failed practice had the potential to delay the admission and hemodialysis treatment of a patient requiring isolation. The facility census is 14. Findings are: A. Review of the undated facility policy, titled Safety Management Plan, revealed the building in which dialysis services are furnished will be constructed and maintained for the safety of the patients. B. Review of the undated facility policy, titled Facility Safety, revealed all equipment and supplies must be properly stored. C. Review of the undated facility policy, titled Transmission-Based Precautions (Isolation Precautions), revealed if a doctor orders a patient to be dialyzed in the isolation room, then the patient will be placed in the isolation room with dedicated supplies and equipment. D. Review of the undated facility policy titled, Hepatitis Guidelines in Dialysis, revealed patients positive for hepatitis B must dialyze in an isolation room with dedicated supplies and equipment. E. Review of the monthly facility physical building audit, completed by the Office Manager on 7/21/25, revealed the isolation room was noted as currently being used for storage. F. During observation of the facility isolation room on 8/11/25 at 10:20 AM with the Registered Nurse (RN) Unit Manager (UM) the following general patient supplies were identified as stored in the isolation room: 1. 5 sealed drums containing 55 gallons each of acid dialysate (an acid based fluid used to filter a patient’s blood during hemodialysis). 2. 65 boxes containing 12 bicarbonate bibags each (a single-use, sealed bag containing dry sodium bicarbonate used to filter a patient’s blood during hemodialysis). 3. 7 boxes containing 4 gallons each of distilled white vinegar (used for maintenance and cleaning of the hemodialysis machines). G. During staff interview on 8/12/25 at 1:00 PM, the RNUM revealed that they had advised staff to utilize the isolation room for overflow storage in July as the facility was overstocking to avoid a supply shortage in the event the 2026 budget was delayed for approval by tribal council (the dialysis facility governing body). The RNUM also revealed they were not aware that the isolation room must be maintained for the purposes of dialyzing patients as it is a federal requirement to maintain Medicare Certification.”

“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: 47269 Based on review of facility policies and procedures, physical building audits, observations and staff interview the facility failed to maintain the building where hemodialysis treatments were provided to ensure safe and sanitary conditions for patients and staff. This failed practice increased the risk of microbial growth with the potential for affecting the health and safety of all 14 hemodialysis patients on census. Findings are: A. Review of the undated facility policy, titled Safety Management Plan, revealed the building in which dialysis services are furnished will be constructed and maintained for the safety of the patients. B. Review of the facility physical building audit of the patient treatment floor, completed by the Office Manager on 7/21/25, revealed a nonfunctional wall bolted patient scale was in need of removal and the walls (unspecified) of the patient treatment floor were in need of repair and paint. C. During observation of the facility hemodialysis treatment floor on 8/11/25 at 10:00 AM with the Registered Nurse (RN) Unit Manager (UM) the following areas were identified and confirmed as needing removal, repair and paint: 1. A wall bolted nonfunctional patient scale, no longer in use, located across from patient treatment station 6, was in need of removal. 2. The painted walls adjacent to wall boxes labeled 1, 2, 6, 8 and 9, located in the patient treatment area, presented with gouges and chipped paint throughout. D. During staff interview on 8/12/25 at 1:00 PM, the RNUM confirmed they had failed to submit work orders to remove the wall bolted nonfunctional patient scale and to repair and paint the walls adjacent to wall boxes labeled 1, 2, 6, 8 and 9, located in the patient treatment area.”