Rogosin West Side Dialysis

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2 hour duration is provided automatically in accordance with 7.9. 20.2.9.1, 21.2.9.1, 7.9 This Standard is not met as evidenced by: 36207 Based on document reviews, and staff interviews, the facility did not maintain, inspect, and test emergency lighting of at in accordance with NFPA 101, 2012 edition. Failure to maintain emergency lighting systems could negatively impact evacuation during emergency. Findings Include, During the document review on 11/06/2024 at 1:30 p.m., it was noted in the facility’s “Emergency Light Log” for 2022, 2023 and 2024 that the facility did not conduct annual 1-1/2 hours functional testing for the emergency light systems. An interview with staff C (Biomed Equipment Technician) on 11/06/24 at 1:45 PM, confirmed this finding. The above finding was brought to the attention of Staff A, Facility administrator during the onsite exit conference on 11/06/2024 at 2:45 PM.”

“Maintenance, Inspection & Testing - Doors CFR(s): This Standard is not met as evidenced by: 36207 Based on observations, document reviews, and staff interviews, the facility did not maintain, inspect, and test fire-rated door assemblies, according to the NFPA 80, 2010 edition. Failure to maintain Fire doors could negatively impact the closing of fire doors in case of fire. Findings Include, During the facility tour on 11/06/2024 between 10:30 a.m. and 11:30 p.m., 1) it was noted that the 90-minute fire rated 2-leaf doors between the main waiting area and elevator corridor, when closed the clearance between both leaves was more than 1/8”. According to NFPA 80, Section 6.3.1.7.1 - Swinging Doors with Builders Hardware, the allowable clearance for meeting edges for a pair of doors is 1/8”. 2) A 45- minutes fire rated door for water room in the dialysis center did not have a fire rating label at the time of survey. During the document review on 11/06/2024 at 1:30 p.m., it was noted that there were no written inspection records for Testing of the fire door assembly available for review. An interview with staff C (Biomed Equipment Technician) on 11/06/24 at 1:45 PM, confirmed this finding. He further stated that he was not aware of the requirement. The above finding was brought to the attention of Staff A, Facility administrator during the onsite exit conference on 11/06/2024 at 2:45 PM.”

“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: 22676 Based on observation, interview, facility policy review and review of Centers for Disease Control (CDC) guidance, the facility failed to ensure that the wall boxes (dispensing outlets) at dialysis stations five of 28 was cleaned and the buildup of yellow substance removed. This deficient practice had the potential to cause bacteria to grow in the wall boxes and cause harm by infecting the 125 patients receiving in-center hemodialysis at the facility. Findings included: Observation of the wall boxes on 06/05/24 2:25 PM, Stations 1-5 revealed a dark yellow sediment with white sediment build-up on the wall boxes. During an interview on 06/06/24 at 10:30 AM the Biomed stated that he/she did not know when the wall boxes were to be cleaned. He/She confirmed that boxes One- Five were visibly dirty with a dark yellow build up. Review of the facility policy titled, “Disinfection of Wall Boxes,” dated 01/28/20, indicated, “Disinfect wall box with disinfectant wipes.” Review of the “CDC Dialysis Safety,” located on the CDC website at www.cds.gov titled, “Wall boxes and Drains” indicated, “All box surfaces should be disinfected at least daily (e.g., at the end of the day after all patients have dialyzed); cleaning and disinfection might be needed more frequently (e.g., when visibly dirty). Cleaning and disinfection of the wall box should be performed after the patient has left the station, and not during patient care activities... More than one disinfectant wipe or application may be needed to ensure all wall box surfaces are visibly wet with disinfectant to achieve contact time specified by the manufacturer.””

“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: 18750 Based on observation, interview, and review of the facility’s policies, the facility failed to ensure three of four oxygen concentrators had the dust filter covering the air intake area of the casing. This deficient practice had the potential to allow debris to enter the oxygen concentrator and could affect the patients breathing. Findings include: Review of the facility policy titled, “Preventive Maintenance Schedules for Equipment,” revised 02/25/20 revealed, “Purpose: To ensure that the dialysis machines and all other ancillary equipment are kept in good working condition and are operating properly. Policy. . . 5. All miscellaneous equipment will receive a preventive maintenance at least twice an annually (e.g. scale, EKG machine, O2 concentrator) . . .” During tour of the facility on 06/05/24 at 10:40 AM, Patient (P)13 was located at Station 12. P13 was wearing a nasal canula attached to a concentrator that had no filter covering the air intake area which the air is taken into the machine to create oxygen. Also, during the tour two concentrators were noticed to be at the other end of the treatment room floor with no filters covering the air intake area. During an observation on 06/06/24 at 12:25 PM, P13 located at Station 2 was placed on a concentrator without a filter covering the grid. During an interview on 06/06/24 at 12:30 PM, the Nurse Manager (NM) was shown the concentrator and asked if it should have a filter cover the air intake area. The NM stated, “Yes. There should be a black sponge-like filter covering the area.” We went back to look at the other concentrators that were bagged and ready for use. The two concentrators did not have filters either. The NM stated they should all have filters.” The NM was asked who makes sure there are filters on the concentrators and that they are lean and ready to go. The NM stated Biomed should make sure the filters are on the machines. During an interview on 06/06/24 at 12:40 PM, the Biomed was asked about the concentrators and the missing filters. The Biomed stated, “There should be a dust filter on the concentrator covering the grid where the air goes into the machine. This will keep debris from getting into the machine.””

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 22676 Based on observation, interview, and review of the policy, the facility failed to ensure patients the hemodialysis access sites were uncovered and visible for one of three days of the survey. The patient and the access site (faces, needle insertion sites and line connections) must always be visible to staff during treatment, to ensure the lines and needles do not become dislodged or disconnected. Excessive blood loss can result from needle dislodgement, resulting in dire consequences such as severe hypotension, hospitalization, blood transfusions, and death, and could affect all 125 in-center hemodialysis patients receiving care at the facility. Findings include: During a tour on the treatment floor with the Nurse Manager on 06/05/24 at 10:56 AM Patient (P) 12 at Station 7, was observed with a blanket covering his/her Central Venous Catheter (CVC) lines. Certified Clinical Hemodialysis Technician (CCHT) 1 was observed walking by the patient and he/she did not have the patient uncover his/her access. An interview with CCHT1 on 06/05/24 at 11:00 AM, confirmed that he/she was assigned to P12, and he/she did not have the patient to uncover his/her access. CCHT1 stated that he/she was not aware of the CVC lines and connection needed to be uncovered. An interview with the Nurse Manager on 06/05/2024 at 11:00 AM confirmed that P12’s access and lines were covered by a blanket and the staff failed to ask the patient to uncover the access. Review of the facility’s policy titled, “Treatment Monitoring” revision date February 1, 2000, indicated, “The vascular access status and line connections and access site to remain visible at all times ...””