322518 Las Vegas NM Dialysis (Fmc)

“Primary/Alternate Means for Communication CFR(s): §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: 46375 Based on record review and interview the facility failed to maintain a written emergency preparedness communication plan that includes the primary and alternate means for communicating with staff, Federal, State, tribal, regional and local emergency management agencies. This failed practice can lead to delay in care, harm or death for all clients and staff. The findings are: A. Record review of the facility’s Emergency Preparedness plan dated 01/01/2024 revealed the Emergency Preparedness plan did not contain any primary or alternate means of communication with staff, Federal, State, tribal, regional and local emergency management agencies. B. During an interview on 10/22/2024 at 3:32 pm with Staff (S)1, non-clinical, when asked if there were alternate means for communication in the emergency preparedness plan, S1 confirmed that the facility did not have any means of communication.”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 50656 Based on observation, interview and policy review, the facility failed to ensure staff practiced proper hand hygiene prior to touching patients while performing patient care. This deficient practice has the potential to expose all patients receiving care to be exposed to potentially infectious pathogens (organisms that can lead to illness) exposure while receiving hemodialysis treatments. The findings are: A. Record review of the facility’s policy titled “Hand Hygiene” dated 11/06/2023, on Page 1 stated “Hands Will Be ...[sic] Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water before and after direct contact with patients. “Hands Will Be ...[sic] Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water after contact with inanimate objects near the patient.” B. On 10/21/2024 at 2:14 PM Staff (S)3 clinical staff member, touched the input computer screen on the hemodialysis machine with a gloved hand, then placed a blood pressure cuff around the arm of a patient beginning hemodialysis treatment without changing gloves or performing hand hygiene. C. During an interview on 10/21/2024 at 2: 19 PM with S3, clinical staff member, S3 was asked if she was required to change gloves after touching the input computer screen on the hemodialysis machine and before touching a patient. S3 replied “No, that machine has been cleaned.””