Bcrd Bronx Center for Renal Dialysis

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for four continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 41886 Based on document review and interview, the facility did not ensure the emergency power supply (EPS) was maintained and tested in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, 2012 Edition. Findings: As per NFPA 110, the generator shall be exercised annually, with supplemental loads not less than 50 percent of the EPS nameplate kW rating, for 30 continuous minutes; and not less than 75 percent of the EPS nameplate kW rating, for 1 continuous hour, for a total test duration not less than 1.5 continuous hours. The facility’s Generator Test Logs, dated from 01/2023 to 08/2024, revealed that the generator failed the monthly 30% load tests exercised from 01/2023 to 08/2024. For the generator named GENERAC (Model SD200), the nameplate kilowatt (kW) rating was 200 kW. The load reached 17 kW during each month’s load test from 2023 to 2024. There was no documented evidence that the annual 1.5 hours load test was performed after the failed monthly 30% load tests. During interview of Staff A (Maintenance Director) on 8/9/2024 at 1:05 PM, Staff A acknowledged that the facility’s generator failed the monthly 30% load test. Staff A stated that they were not aware of the additional requirement to conduct an annual load test in such cases. The facility failed to ensure the maintenance and testing of the emergency power supply was conducted in accordance with NFPA 110.”

“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: 28297 Based on observation, interview and policy review, the facility failed to ensure that visitors in the treatment area wore Personal Protective Equipment (PPE) as required for one of three survey days. The failure for visitor to wear PPE as required had the potential for exposure to bloodborne pathogens and this could affect 115 in-center patients. Findings include: Observation on 08/06/24 at 12:15 PM revealed Certified Clinical Hemodialysis Technician (CCHT) 1 was at Station 11 putting on Patient (P) 11 via fistula (a permanent access that connects a vein and artery used for hemodialysis) in the left arm. A visitor (sitter) was sitting in a chair the entire time without any protective grown. During an interview with CCHT1 he/she stated they did not know the visitor needed to wear a protective gown. Observation on 08/06/24 at 12:25 PM the CCHT2 at Station 6 putting on P12 via fistula in the left arm. A visitor was sitting in a chair the entire time without any protective grown. During an interview with CCHT6 he/she stated they did not know the visitor needed to wear a protective gown. During an interview on 08/07/24 at 11:20 AM the Nurse Manager confirmed that the visitors did not have on PPE and that visitors who are in the treatment area during initiation and termination of treatment should have on protective gowns to prevent exposure to bloodborne pathogens. Review of the facility’s policy titled, “Visitor Policy,” effective 03/2020, indicated, “ ...Visitors may be allowed in the hemodialysis treatment area at the discretion of the dialysis Nurse Manager or Charge Nurse. Visitors are not allowed in the treatment area during initiation and termination of the dialysis treatment unless permitted to do so based on the needs of the patient i.e. they are utilized during dialysis to sit with a patient to prevent harm ...The visitor should be offered an impervious gown while in the treatment area. The gown should be fully closed in front ...””

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 28297 Based on observations, interview, and Manufacture Directions for Use, the facility failed to follow the recommendations for dialysis (an artificial means of kidney function that removes the waste and excess fluid from the blood by passing it through a filter) treatments by not maintaining the arterial drip chambers (a pressure and air monitoring component of the dialysis bloodline tubing) fluid levels at 85-95% full for two of three survey days. Failure to follow the Manufacture Directions for Use (DFU) had the potential to result in equipment malfunction and/or failure and negatively impact the safety and wellbeing of the 115 patients receiving dialysis treatments in this facility. Findings include: 1. Observation of the hemodialysis treatment area on 08/05/24 revealed the following: At 12:30 PM, the arterial drip chamber fluid levels were less than 25% full at Stations 3, 4 and 5. Certified Clinical Hemodialysis Technician (CCHT) 3 confirmed the arterial drip chambers were low at Stations 4 and 5 and should be greater than 75 % full to prevent air from getting into the extracorporeal system 2. Observation of the hemodialysis treatment area on 08/06/24 revealed the following: At 1:00 PM the arterial drip chamber at Station 4 and 18 were less than 25 % full. CCHT2 confirmed the arterial drip chambers were low and should be greater than 75 % full to prevent air into the extracorporeal system. During an interview on 08/07/24 at 11:20 PM the Nurse Manager confirmed the arterial drip chambers should always be 75% to 85% full to prevent air from getting into the extracorporeal system. Review of the undated manufacture directions for use (DFU) provided by the facility for “Combi Set True Flow Series Hemodialysis Blood Tubing Set with Priming Set and Transducer Protectors,” indicated, “ ...Prime pre-pump, arterial chamber 85-95% full, post pump arterial and venous chamber 65-75% full ...During Treatment Periodically check the extracorporeal circuit for any evidence of possible Separation or leak. Maintain fluid level in pre-pump arterial chamber at 85%-95% full, post pump arterial and venous chambers at 65-75% full ...””