Fmc Los Paseos

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 47384 Based on a ESRD Core recertification survey and observations made of the treatment area, during the first shift of 03/19/2024 from 8:30 AM through 1:00 PM , it was determined that the facility failed to mantain a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent areas. Findings include: 1. Isolation gowns on hanging rack on unit entrance were observed with tie straps touching the floor. 2. Exesive dust particles was observed on all counter top areas through out the unit.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 15884 Based on a ESRD Core recertification survey and observations made of the treatment area, during the first shift of 03/19/2024 and 03/20/2024 from 8:30 AM through 1:00 PM , it was determined that the facility failed to ensure that patients follows instructions related with the hazards of eating while on dialysis for 9 out of 32 observations at patient’s stations #18, #29,#36,#40,#41,# 45,# 49, #56 and #60. Findings include: Review of facility’s Policy &Procedures, # 45279 FMS Clinical Services Eating and drinking hot liquids policy last updated on 02/01/2023 established that only physician prescribed liquid nutritional supplements approved by the Registered Dietitian shall be consumed while on dialysis. The physician prescribed solid supplements must be consumed in the patient waiting area prior to or following the dialysis treatment. 1. During observations performed on 03/19/2024 from 8:30 AM through 1:00 PM at the hemodialysis treatment areas, it was observed that four out of thirty-two patients were eating salty snacks and candy while receiving their hemodialysis treatment at stations (#29, #45, # 49 and #60). 2. During observations performed on 03/20/2024 from 8:30 AM through 11:35 AM at the hemodialysis treatment areas, it was observed that five out of thirty-eight patients were eating salty snacks and candy while receiving their hemodialysis treatment at stations (#18, #36, #40, #41 and #56). 3. Facility failed to discourage the consumption of food (salty snacks & candy) while on hemodialysis treatment to comply with infection standards and facility policies and procedures.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 15884 Based on an unannounced recertification CORE survey, observational tour of the patient treatment area during the first on 03/19/2024 and interview with facility manager (employee #9), it was determined that the facility failed to ensure that dialysis facility is equipped, to provide dialysis patients clean and comfortable treatment environment for 4 out of 58 patients on the first shift of 03/19/2024, practice who had the potential to affect 58 out of 58 patients on the first shift of 03/19/2024. Findings include: 1. The following was identified on 03/19/2024 at 9:30 AM during the first shift of hemodialysis. a. Station #14 had a hemodialysis chair whose right-side table was observed with reddish spots. b. Station #11 had a hemodialysis chair whose right-side table was observed with reddish spots. b. Station #7 had a hemodialysis chair whose right-side table was observed with reddish spots. c. Station #6 had a hemodialysis chair whose right-side table was observed with reddish spots. d. Station #1 had a hemodialysis chair whose right-side table was observed with reddish spots. 2. During the interview on 3/19/2024 at 3:30 PM facility manager (employee #9) stated that they recently noticed that some hemodialysis chair side tables have reddish spots. She explains that due to it was impossible to remove those reddish stains facility decide send to buy new side tables in order to change those that had the stains.”

“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: 47384 Based on a ESRD Core recertification survey and observations made of the treatment area, during the first shift of 03/19/2024 from 8:30 AM through 1:00 PM , it was determined that the facility failed to implement and maintain a program to ensure that all equipment are maintained and operated in accordance with the manufacturer’s recommendations. Findings include: 1. Broken vinyl was observed on treatment chairs on stations #1, #17, #50. 2. Lighting fixture was found flashing because of disfuctional light bulb in front of station #3. 3. 2 labtop cables were observed with broken charging cable. This two charging cables were conected to power sucket located on hand washing stations. 4. Two strechers were observed with broken components, rust and exesive dust on stations #18 and #24 5. No emergency desconection kit was found station #5. 6. Only one emergency desconection kit was observed in treatment stations #22, #33, #60”

“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: 15884 Based on an unannounced ESRD Core recertification survey, the observational tour and review of policies and procedures, and interview with facility nursing supervisor ( employee #2), it was determined that the facility failed to ensure that patients receive treatment in a manner that allows staff to have full view of patient’s access sites for the first shift and second shift during on 03/20/2024 from 8:35 AM thru 11:35 AM at patient’s stations #25, #28, #35 and #54. This deficient practice affects 4 out of 58 patients observed receiving treatment. Findings include: 1. During observations of the hemodialysis treatment area on 03/20/2024 from 8:35 AM thru 11:35 AM the following was identified: Upon review of the facility’s policy # 45284 Patient assessment and Monitoring last update on 05/01/2023, on 03/20/2024 at 1:30 PM. Policy clearly stated that during dialysis personnel in charge must ensure vascular access remain uncovered throughout the treatment. a. Patient located on station #25 was observed with line connections located on left arteriovenous fistula covered with blankets while receiving treatment. b. Patient located on station #28 was observed with her right leg graft vascular access and line connections covered with a blanket while receiving treatment. c. Patient located on station #35 was observed with his right femoral vascular access and line connections covered with blankets. d. Patient located on station #54 was observed with his left arm arteriovenous fistula vascular access connections covered with blankets while receiving treatment. 2. Facility nursing supervisor (employee #2), stated on interview on 03/20/2024 at 12:17 PM as per policy established that if nursing identifies that vascular access and line connections are not visible, they must request to their patient to uncover the vascular access. She stated that policy established indicates that nursing personnel must educate and explain to the patient as a manner that the patient understand about the risks associate if not maintain the vascular access visible at all time during the treatment. 4. The facility failed to promote policies and procedures that establish that access sites are to be left uncovered to allow complete visibility by the nursing staff, during hemodialysis treatment.”

“PE-FIRE SAFETY-LIFE SAFETY CODE CFR(s): 494.60(e)(1) (1) Except as provided in paragraph (d)(2) of this section, dialysis facilities that do not provide one or more exits to the outside at grade level from the patient treatment area level must comply with provisions of the Life Safety Code (NFPA 101 and its Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4) applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. This Standard is not met as evidenced by: 47384 Based on a ESRD Core recertification survey and observations made of the treatment area, during the first shift of 03/19/2024 from 8:30 AM through 1:00 PM , it was determined that the facility failed to mantain Life Safety measures that complies with NFPA 101 provisions which could affect 58 of 58 recieving treatment and staff. Findings include: 1. Loaded sprinklers were observed in front of treatment stations #7, #35, #44. 2. Regular trash can was observed in front of the emergency exit located towards the rear parking lot obstructing the emergency exit passage way.”