Dci Seven Fields

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 31759 Based on review of facility policy, observation, and staff (EMP) interview, the facility stored unused supplies intended to be clean on the hemodialysis machines (dirty area) for 16 of 17 hemodialysis stations (ST 1-15, & ST 17). Findings included: Review of facility policy on September 16, 2025, at 12:46 p.m. showed, “PROCEDURE NO: 310 ... General Facility Infection Control ... POLICY: ... 6. Clean areas should be clearly designated for the preparation, handling, and storage of medications and unused supplies and equipment.” Observation of patient treatment area on September 15, 2025, at 10:30 a.m. revealed each hemodialysis machine (not a clean area) had several unused packages of “Recirculation connector Sterile Contents Single Use” taped to the top of the machine and oriented so that the packages would hang at the back of the machines. At this time, multiple patients initiated and terminated treatment with the same recirculation connectors taped to the back of the dialysis machines. Further observation of the patient treatment area was conducted on September 17, 2025. At 9:45 a.m., a patient left station 4 after dialysis was completed, and three (3) packages of recirculation connectors were observed taped to the back of the machine. EMP7 wiped the machine and station down and prepared it for the next patient. The next patient initiated dialysis at 11 a.m. with the same three (3) packages of recirculation connectors taped to the back of the machine present during the previous treatment. At 10 a.m., a patient left station 13 after dialysis was completed, and three (3) packages of recirculation connectors were observed taped to the back of the machine. EMP6 wiped the machine and station down and prepared it for the next patient. The next patient initiated dialysis at 10:50 a.m. with the same three (3) packages of recirculation connectors taped to the back of the machine present during the previous treatment. At 11:40 a.m., EMP1 observed the machines on the treatment floor and noted that 16 of 17 available machines had 3-4 recirculation connectors taped to the back. Interview with EMP1 on September 17, 2025, at 11:42 a.m. confirmed above findings. EMP1 confirmed items were intended for patient use and taped to the back of the machines if recirculation is needed during an emergency.”

“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: 31759 Based on review of facility policy, observation of patient treatment area, and staff (EMP) interview, the facility failed to ensure the surface for nine (9) of 18 in-center hemodialysis treatment chairs (HDC) located in the hemodialysis patient treatment area were intact and maintained free from defects to allow for effective cleaning to limit the potential for microbial growth on a porous surface (HDC 1, 5-7, 9, 13, 15, 16, & 18). Findings included: Review of “DIALYSIS CLINIC, INC. FACILITY SAFETY INSPECTION” document on September 16, 2025, at 12:30 p.m. showed, “M. Patient Care Areas - Hemo & Home Training ... n. treatment chairs free of tears & broken mechanisms.” Observation of patient treatment area dialysis chairs on September 15, 2025, at 11:30 a.m. and again on September 16, 2025, at 10 a.m. with EMP1 (clinic manager) revealed the upholstery of seven (7) of 18 hemodialysis chairs had damaged upholstery exposing the porous material beneath, and two (2) had adhesive tape and adhesive tape residue. Dialysis chairs (HDC) at stations 1, 5, 6, 13, 16, and a spare dialysis chair (HDC 18) available for use next to station 15, had ripped corners on the chair’s head rest area. The dialysis chair at station 9 had a large rip/gash on its left inside portion of the side panel. Dialysis chairs at stations 7 and 15 had adhesive tape and adhesive tape residue on them. Interview with EMP1 on September 16, 2025, at 10:30 a.m. confirmed above findings.”