322533 North Rio Rancho Dialysis (Fmc)

“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: 47302 Based on record review, observation and interview the facility failed to ensure the emergency crash carts and box (cart and box filled with supplies to be easily accessed in case of an emergency) were checked for all supplies, expiration dates and locked to ensure security of supplies; this could affect all patients treated in the facility. This deficient practice could lead to the facility not being prepared for an emergency event if the emergency supplies are missing or expired. The findings are: A. Record review of facility’s policy titled, “Emergency Medications, Equipment and Supplies” dated 05/01/2023, on page 2 under “Emergency Cart” stated, “The emergency cart must be: -Locked when not in use - Checked monthly or after use for contents, expiration dates, cleanliness, and proper functioning of all equipment. . .” B. During an observation on 03/26/2024, at 8:45 AM, in the home training room the emergency crash cart was unlocked. C. During an observation on 03/28/2024, at 9:45 AM, the emergency evacuation box [box to be utilized in the case of an evacuation of the facility that contains emergency supplies] was observed with two break away, disposable locks that were not locked. D. Record review of monthly monitoring logs, for the crash cart located in the home training department, from January 2024-March 2024 revealed the log was not completed to show monitoring of the crash cart to check for expired or missing supplies. E. During an interview on 03/28/2024, at 10:00 AM, with Staff (S)9, Charge Nurse it was confirmed that crash carts should be locked. S9 also confirmed that the crash carts and box are checked monthly. F. During an interview on 03/27/2024, at 4:00 PM, with S8, ATOM (Area Technical Operations Manager) it was confirmed that there were missing logs for the crash cart in the home training department.”

“Development of Communication Plan CFR(s): §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This Standard is not met as evidenced by: 47302 Based on record review and interview the facility failed to have a written emergency communication plan in place that contains how the facility will coordinate patient care within the facility, across healthcare providers, and with state and local public health departments. This deficient practice could affect all patients, it could lead to patients not receiving dialysis in the case of an emergency. The findings are: A. Record review of the facility’s emergency plan dated 08/08/202,3 under “Section 5 - Communication Plannin [sic]” revealed an outline of what needs to be included in a communication plan. There was no evidence that a communication plan had been created for the facility. B. During an interview on 03/27/2024, at 3:45 PM, Staff (S)1, Director confirmed that the facility did not have a communication plan in the emergency plan.”

“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: 47302 Based on record review and interview the facility failed to include a primary and an alternate means of communication in the emergency plan. This deficient practice could affect all patients, it could lead to patients not being updated in the case of an emergency. The findings are: A. Record review of the facility’s emergency plan dated 08/08/2023 under “Section 5 - Communication Plannin [sic]” revealed an outline of what needs to be included in a communication plan. There was no evidence of the facility’s primary and alternate means of communication. B. During an interview on 03/27/2024, at 3:45 PM with Staff (S)1, Director, when asked what the alternate means of communication was. S1 stated that they would utilize the analog phone and e-mail. S1 confirmed this was not written in the communication plan.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 49835 Based on interviews and observation, the facility failed to ensure that 3 (S [staff] 3, S5, and S6) of 8 ( S2, S3, S4, S5, S6, S7, S18 and S19) staff members wore gowns or cover garment which provides a barrier to fluids and/or contaminated surfaces to protect and prevent soiling of clothing when procedures were performed during initiation and/or termination of dialysis treatment. This deficient practice can lead to exposure of infected bodily fluids and /or contaminants. The findings are: A. During an observation on 03/27/2024, at 8:00 am S5, RN (Registered Nurse) provided care to patients that received hemodialysis in the following dialysis stations (Stations #10, #12, and #21). S5 did not wear a gown. B. During an interview on 03/27/2024, at 8:00 am, S5 was asked if a gown should be worn, she replied “I have no reason for not wearing one.” C. During an observation on 03/27/2024, at 9:14 am, S3 RN went to Dialysis Station #21, then to station #22 without wearing gown, during this observation S5 was observed telling S3 to put a gown on which she complied with and put a gown on. D. During an observation on 03/27/2024, at 10:16 am, S7, Technician was terminating a dialysis session, S7 did not wear eye protection. E. During an interview 03/27/24, at 10:00 am, with S7, Technician was asked if eye protection should be worn, S7 stated “Yes, I forgot to put them on.” F. During an interview on 03/27/2024, at 10:00 am, with S1, Director of Operations when asked if staff should be wearing gowns and eye protection, S1 stated “Yes, if they are providing patient care.””

“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: 49835 Based on observations and interviews the facility failed to provide an environment that can be cleaned and disinfected in the dialysis center. This deficient practice places all patients at risk for infection. The findings are: A. During an observation of the dialysis stations #3, #8 and #20 on 03/27/2024, at 3:30 pm, the dialysis stations #3, #8 and #20 had areas of sheet rock exposure, these areas cannot be cleaned or disinfected. B. During an interview on 03/27/2024 at 3:30 pm with S1, Director of Operations when asked if these areas can be cleaned and disinfected. S1 stated “No you can’t fully clean or disinfect sheetrock.” C. During an interview on 03/27/2024 at 3:30 pm with S8 Area Technical Operation Manager, it was asked if the areas of exposed sheet rock can be cleaned and disinfected. S8 stated “No, there is no way it can be it’s too porous (many small holes, so air and liquid can pass).”

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 49835 Based on observation, record review and interview the facility failed to monitor and replace sharps containers when needed. Not replacing the full sharps container can cause harm and possible infections to staff. The findings are: A. Record review of the facility’s policy titled “General Cleanliness and Infection Control Guidelines” Dated 02/07/2022, on page 3 of 6, section titled Contaminated Needles and Sharps Container it stated, all containers for storage or disposal of needles/sharps shall be replaced on a regularly scheduled basis or when no more than 2/3 to 3/4 full. The container must be closed prior to being full. B. During an observation of the dialysis stations #3, #5, #6, #7 and #8, on 03/27/2024, at 8:30 am, there were numerous sharps containers located at dialysis stations #3, #5, #6, #7 and #8, had used tubing previously used on a dialysis patient and needles coming out the top of the sharp containers. Staff continued to place needles and lines into the full sharp container. C. During an interview on 03/27/202,4 at 9:15 am, with Staff (S)8, Area Technical Operations Manager was asked if it is normal that the sharps containers are full, S8 stated “No they should be routinely changed out before they get that full.””

“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: 49835 Based on observation and interview the facility failed to ensure the safety of the staff by not maintaining a medication refrigerator door handle. This deficient practice places has the potential to cause injury or harm for all staff using the refrigerator. The findings are: A. During an observation of the medication refrigerator, on 03/27/2024 at 3:30 PM, the handle on the medication refrigerator was broken and had very sharp edges. B. During an interview on 03/27/2024, at 3:30 PM, with Staff (S)1, Registered Nurse (RN), it was asked if the handle was safe for the staff. S1 stated “No, I didn’t know the handle was broken.” C. During an interview on 03/27/2024, at 3:30 PM, with S8 Area Technical Operations Manager it was asked is the the medication refrigerator handle was safe for staff to open the refrigerator door with those sharp edges, S8 stated “Not at all, someone could get hurt with the sharp edges.””