Atlantic Dms - Elmhurst Hospital Broadway

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas must meet one of the following: *Contain 1 hour rated enclosure when non-sprinklered *Sprinkler protected with smoke resistive separation *Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors 20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7 This Standard is not met as evidenced by: 19043 Based on observation and interview, it was determined that the facility did not ensure that (a) all hazardous areas are safeguarded from other spaces by fire/smoke resisting partitions, and (b) doors which are self-closing or automatic-closing and/or are provided with the positive latching devices. Findings include: During the tour of the facility on 11/07/24 at approximately 10:30 AM, the surveyor noted that the facility had re-purposed an office D7-17 into a dialysis supply storage room. The surveyor observed four big cardboard boxes and other dialysis supplies in bins stored on a metal rack inside this room. This re-purposed storage room with a sprinkler head was not protected by smoke resistive partitions on all sides and a self-closing door with positive latching device. Per Interview of Staff B on 11/07/24 at 10:45 AM, the facility converted an office to a storage room due to lack of adequate storage space for dialysis supplies without confirming that the room was constructed in accordance with NFPA 101 requirements to be converted into a storage room. Staff B confirmed this finding.”

“ESRD Patient Orientation Training CFR(s): The dialysis facility must provide appropriate orientation and training to patients, including the areas specified in paragraph (d)(1) of this section. This Standard is not met as evidenced by: 26190 Based on record review, interview and policy review the facility failed to document in the patient’s medical record the completion of emergency preparedness (EP) training with patients for six (P1, P3, P4, P5, P11, P12) of 15 patients sampled. Findings include: Review of the facility “Face Sheets,” provided by the facility revealed the following: Patient (P) 1 was admitted to the facility on 04/16/24 with one of his/her diagnosis being End Stage Renal Disease (ESRD). P3 was admitted to the facility on 12/10/23 with one of his/her diagnoses being ESRD. P4 was admitted to the facility on 05/01/24 with one of his/her diagnoses being ESRD. P5 was admitted to the facility on 06/03/24 with one of his/her diagnoses being ESRD. P11 was admitted to the facility on 10/25/22 with one of his/her diagnoses being ESRD. P12 was admitted to the facility on 01/07/22 with one of his/her diagnosis being ESRD. During an interview on 06/21/24 at 9:15 AM with the Administrator, he/she confirmed that the Social Worker (SW) was the staff member in charge of completing the EP education with patients and documenting the completion of the education in the patient’s medical record. During an interview on 06/21/24 at 9:35 AM, SW stated prior to COVID (Coronavirus Disease 2019) pandemic, after completing the EP education with a patient he/she would have a patient sign an education sheet as documentation the education was completed. SW said he/she discontinued doing the signature process during COVID because patients did not want to touch a lot of papers. The SW stated he/she had not returned to using the signature process even though the majority of the COVID precautions had been lifted. Review of the facility’s policy titled, “Patient Education,” dated 12/28/08, did not address patient education in regards to emergency preparedness. Review of the facility’s policy titled, “Emergency Preparedness Program,” dated 02/14/24, stated, “Policy: The Dialysis Center will develop a Dialysis Unit Emergency Preparedness Program (DUEPP) that will be reviewed and edited annually as necessary ...9. Training and Testing: a. Patients ...will be instructed at least yearly in the DUEPP ...””

“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: 28297 Based on observation, interview, and policy review, the facility failed to ensure patients washed or sanitized hands after holding access sites (A vascular access is created so that blood can be drawn from the body and run through a dialysis machine, where excess fluid and toxins are removed from the blood. (i) The filtered blood then flows back through the access into the body) for two of three survey days. The failure for patients to wash or sanitize hands after holding access site had the potential for cross contamination and could affect 153 in-center patients. In addition, the facility failed to ensure staff wash or sanitized hands after glove change for one of three survey days. The failure to wash or sanitize hands between glove changes had the potential for contamination and could affect 153 in-center patients. Findings include: 1. a. Observation on 06/19/24 at 1:25 PM revealed Patient (P) 5 at Station 16 applied pressure to the left lower arm access site until bleeding had stopped. When finished the patient removed his/her glove and Certified Hemodialysis Technician (CHT) 2 assisted the patient to the scale to retrieve his/her weight. The patient did not wash or sanitize hands and CHT2 did not instruct or encourage the patient to wash or sanitize their hands. During an interview on 06/19/24 at 1:45 PM, CHT2 acknowledged P5 did not wash or sanitize hands after holding access site and he/she did not instruct or encourage the patient to prevent cross contamination. b. Observation on 06/20/24 at 9:25 AM revealed P17 at Station 16 held pressure to his/her left lower arm access site. After the bleeding had stopped CHT-3aped up the access site. The patient removed his/her glove, gathered belongings and CHT3 walked with the patient to the scale to retrieve the patient’s weight. The patient left the unit without washing or sanitizing hands and CHT3 did not instruct or encourage the patient to wash or sanitize their hands. During an interview on 06/20/24 at 9:45 AM CHT3 acknowledged P17 did not wash or sanitize their hands after holding their access sites but should have to prevent cross contamination. 2. Observation on 06/19/24 at 1:05 PM revealed CHT2 was at Station 6 initiating the treatment via left lower arm access for P9. CHT2 disinfected the access site then removed gloves. CHT2 donned new gloves without washing or sanitizing their hands. During an interview on 06/19/24 at 1:15 PM, CHT2 confirmed he/she did not wash or sanitize their hands between glove changes as required to prevent cross contamination. During an interview on 06/21/24 at 12:30 PM Registered Nurse (RN) 1 stated patients should wash or sanitize hands after holding access sites at the end of treatment to prevent cross contamination of blood borne pathogens. RN1 also confirmed staff were required to wash or sanitize hands after glove changes to prevent cross contamination. Review of the facility’s policy titled, “Handwashing Procedure,” revised 07/14/17, indicated, “...Hand hygiene with either hand washing, or alcohol-based rub (may be done more frequently than the times mentioned below): upon arrival on duty, before and after each patient contact, after handling of equipment. Supplies, or environmental surfaces at the patient station, after removal of gloves ...””

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 26190 Based on record review, interview and policy review the facility failed to offer vaccination to all hemodialysis patients against Hepatitis B for one (Patient (P) 4) of 15 sampled patients on hemodialysis. Failure to offer the Hepatitis B vaccine but lead to a missed opportunity for P4 to develop surface antibodies in a timely manner. Findings include: Record review of P4’s “Face Sheet” provided by the facility, revealed the patient was admitted to the facility on 05/01/24 with one of his/her diagnoses being End Stage Renal Disease (ESRD). A review of P4’s medical record revealed a laboratory result, dated 05/02/24, of non-immune/negative which made P4 eligible to receive the Hepatitis B vaccination series. Further review of P4’s medical record revealed no documentation of P4 was offered or given the Hepatitis B vaccine. During an interview on 06/21/24 at 2:50 PM Nurse Administrator (NA) confirmed P4 had not been offered or received the Hepatitis B vaccine as of 06/21/24. The NA explained the normal process was after the facility received a new patient admission the staff would submit the patient’s blood work to the lab and once the lab results were received, within three to five days, the staff would contact the patient’s physician and obtain an order for the Hepatitis B vaccine. Review of the facility’s policy titled, “Hepatitis B Testing and Vaccination for Patient’s and Staff,” dated 07/23 stated, “Policy: It is the policy of the Dialysis Center to screen patients ...according to the CDC’s (Centers for Disease Control) policy statement in Recommendations for Hepatitis B Control in Chronic Hemodialysis Centers ...Who should get the hepatitis B Vaccine? According to the CDC, hepatitis B vaccination is recommended for all susceptible chronic hemodialysis patients ...Patient Guidelines: 1. For patients new to the unit ...draw HepBsAg, HepBsAb, and HepBcAb during first treatment/visit ...8. If HepBsAg negative, If HepBsAb is negative, HepBcAb negative, give patient complete vaccine series to a maximum of 2 vaccination series in an lifetime ...14. Patient immunization record will be completed and maintained in the patient’s medical record ...””

“IC-HBV-ISOLATION (EXISTING FACILITY) CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients To isolate HBsAg positive patients, designate a separate room for their treatment. For existing units in which a separate room is not possible, HBsAg positive patients should be separated from HBsAg susceptible patients in an area removed from the mainstream of activity. This Standard is not met as evidenced by: 28297 Based on observation, interview, and policy review, the facility failed to ensure the door to the Isolation Room was closed during initiation of the dialysis treatment for one of one observation. The failure to close the door had the potential for blood splatter outside the door and could affect 153 in-center patients. Findings include: Observation on 06/20/24 at 10:00 AM Certified Hemodialysis Technician (CHT) 5 initiated the treatment in the Isolation Room for Patient (P) 3 via left lower arm fistula (a vein attached to an artery in the arm to allow an access point for hemodialysis.) P3 is positive for Hepatitis B virus. During an interview on 06/20/24 at 10:15 AM, CHT5 confirmed he/she forgot to close the door during initiation of treatment and should have to prevent potential splatter outside the room. During an interview on 06/21/24 at 12:30 PM, Registered Nurse (RN)1 confirmed the door to the Isolation Room must be closed during initiation and termination of the treatment for patients in isolation for Hepatitis B to prevent to risk of blood splatter. Review of the facility’s policy titled, “Hepatitis Controls for Patients and Equipment,” revised 12/14/17, indicated, “ ...Separate room space and equipment will be provided for these patients. A designated isolation room and machine will be used by hepatitis patients. The door to the isolation room will be closed during procedures (initiation and termination of treatment) ...””

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 28297 Based on observation, interview, and policy review, the facility failed to ensure staff completed the Central Venous Catheter (CVC-A hemodialysis central venous catheter is a type of access used for hemodialysis. CVCs are placed under the skin and into a large central vein, preferably the internal jugular veins. CVCs are meant to be used for a short period of time until a more permanent type of dialysis access has been established.) dressing change prior to initiation of hemodialysis treatments for one of one observation. The failure to change the CVC dressing prior to treatment initiation had the potential for staff to miss potential complications of the CVC by not visualizing the access site and this could affect 24 patients with CVC’s. Findings include: Observation on 06/20/24 at 10:20 AM revealed Registered Nurse (RN) 2 initiated the dialysis treatment at Station 23 for Patient (P) 18 via a CVC. RN2 did not complete the CVC dressing change until after initiation of the dialysis treatment. P18’s CVC had a white square dressing in place over the insertion site not allowing for the RN to visualize the insertion site of the CVC. During an interview on 06/20/24 at 10:35 AM after the dialysis treatment and CVC dressing change was completed for P18, RN2 confirmed he/she initiated the dialysis treatment first and that was his/her normal practice to get the patient started on treatment. RN2 stated he/she should have looked at the insertion site of the CVC to ensure there were no complications with the CVC prior to initiation of the dialysis treatment. RN2 confirmed the dressing over the CVC was not clear and the insertion site was not visible with the white square dressing covering the CVC site. During an interview on 06/21/24 at 12:30 PM, RN1 confirmed the CVC dressing change was required to be changed prior to initiation of the hemodialysis treatment to ensure staff could inspect the CVC insertion site for complications every treatment. Review of the facility’s policy titled, “”Initiation and Termination of Central Venous Catheter with Clear Guard HD [Hemodialysis] End Cap” issued 05/01/18, indicated, “Policy: Placement of a central venous catheter (CVC) will give temporary or long-term blood access for dialysis when permanent vascular access is not present or when vascular access is not usable. Placement usually is in the subclavian vein, internal jugular vein or external jugular vein. The central venous catheter can only be accessed by a nurse. Staff nurses performing the procedure are to have proper PPE equipment before initiating procedure. Staff will set up privacy screens during initiation and discontinuation of treatment when the vascular access is placed in an intimate area. Catheter Dressing is to be changed before patient is connected to dialysis machine at least once per week ...””