Dialysis Center of Westerly

“ENVIRONMENT-SECURE & RESTRICTED CFR(s): 494.40(a) 8 Environment: secure & restricted The water purification and storage system should be located in a secure area that is readily accessible to authorized users. The location should be chosen with a view to minimizing the length and complexity of the distribution system. Access to the purification system should be restricted to those individuals responsible for monitoring and maintenance of the system. This Standard is not met as evidenced by: 21613 Based on surveyor observation, and staff interview, it has been determined that the facility failed to ensure that the water purification and storage systems were secure and only accessible to individuals responsible for monitoring and maintenance of the system for 1 of 1 water purification and storage system areas observed. Findings are as follows: During a surveyor interview with the Clinical Manager on 6/17/2024 at 8:35 AM, she revealed that the entry codes for the doors to the treatment and office/employee areas is the same entry code for the water purification and storage system area door. During a surveyor observation on 6/17/2024 at 8:45 AM, revealed one of the doors to access the water purification and storage system area has the same entry code as the door for the waiting room to the dialysis treatment room and the door for the office/employee areas. During a surveyor observation on 6/17/2024 at 11:30 AM, a delivery person, not employed by the facility was seen in the water purification and storage system area. Additionally, one of the doors in the back of the water purification and storage system area was propped open, allowing direct access to the water purification and storage system area from the outside. Further observation failed to reveal evidence any staff were in the area. During a surveyor interview during the above observation, the delivery person revealed a staff member opened the door for him and left him unsupervised. During a surveyor interview immediately following the above observation with the Clinical Manager, on 6/17/2024 at 11:33 AM, she acknowledged that a staff member had left the delivery person unattended in the water purification and storage system area and that the water purification and storage system area should be accessible to authorized users only. Additionally, she was unable to provide evidence that access to the water purification and storage system area was restricted to those individuals responsible for monitoring and maintaining the system.”

“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: 46539 Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that the water purification, storage supply room, the conductivity (the degree to which a specified material conducts electricity) and pH (acidity or alkalinity of a solution) meters were maintained in accordance with the manufacturer’s recommendations for 1 of 1 water purification and storage system areas observed. Additionally, the facility failed to ensure that the dialysis chair’s upholstery was maintained for 4 of 15 chairs observed. Findings are as follows: 1. Surveyor observations made during the flash tour of the water purification and storage areas on 6/17/2023 at approximately 9:00 AM in the presence of the Clinical Manager revealed, the water purification and storage system areas had an accumulation of dust and a white substance on the bicarbonate mixers, carbon tanks, and floor, as well as other equipment and machinery in the room. Additionally, during the above observation, it was revealed that the water purification and storage area had a large amount of white crystallized matter accumulating on the granuflo (dry acid dialysate, use to help to clean the blood of dialysis patients, who accumulate impurities when their kidneys stop filtering effectively) transfer pipes, and on the wall as well as on the floor surrounding it. 2. During a surveyor observation with the Facility Technical Manager (FTM) on 6/18/2024 at approximately 9:30 AM, revealed rust on the baseboard of the heating system (approximately 10 inches in width x 10 feet in length) in the water purification and storage areas. Further observation revealed the flooring in the water purification, storage and supply rooms had cracked floor tires and scuff marks on the walls. During a surveyor observation with the FTM on 6/18/2024 at 10:55 AM, he acknowledged the above observations and revealed that staff should have cleaned the area. The FTM was unable to provide evidence as to when the water purification and storage system areas were last cleaned. During a surveyor interview with the Clinical Manager on 6/18/2024 at 2:45 PM, she acknowledged the walls and flooring in the facility are in need of repair and/or replacement. 3. During a surveyor observation on 6/17/2024 at 8:49 AM, of the water purification and storage system areas, in the presence of the Clinical Manager revealed 4 bottles of “H&S Conductivity Standard Solution [a solution used to calibrate a meter to check water quality]” that expired on 4/18/2024. During a surveyor interview with the Clinical Manager on 6/17/2024 at 8:50 AM, she acknowledged that the above-mentioned solutions had expired and the expired items should be disposed of. 4. During surveyor observations on 6/17/2024 at 10:35 AM and 12:21 PM revealed, the upholstery on the seats of the dialysis chairs at stations 7 and 14 were torn/cracked. During an additional surveyor observation on 6/18/2024 at 9:43 AM revealed the upholstery on the seats of the dialysis chairs at stations 3 and 9, and were also torn/cracked. During a surveyor interview and observation on 6/18/2024 at 9:45 AM with the Clinical Manager, she acknowledged the upholstery on the seats of the dialysis chairs at stations 3, 7, 9, and 14’s were torn/cracked. During a surveyor interview immediately following the above observation, the Clinical Manager indicated that all the chairs in the facility are utilized at this time and that the facility had ordered 2 new chairs in July of 2023. She was unable to provided evidence that additional the above-mention chairs were going to be repaired or replaced or that there was any follow up with manufacturer related to the order placed in July of 2023. 21613”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 21613 46539 Based on surveyor observation, record review, and staff interview it has been determined that the facility failed to ensure that staff follow the dialysis prescription when administering dialysis treatments for 1 of 4 sample patients reviewed, Patient ID #7. Findings are as follows: Record review revealed Patient ID #7 was admitted to the facility in June of 2024 with a diagnosis of renal sclerosis (hardening of the kidney) and is receiving hemodialysis (a procedure where a dialysis machine and a special filter called an artificial kidney are used to clean the patient’s blood three times a week). Review of the patient’s dialysis prescription revealed a dialysate (a fluid that is used in dialysis treatment that is made up of water, electrolytes, and salt) with potassium 2.0 and calcium 2.5 was ordered to be delivered on 6/17/2024. Further record review of the patient’s treatment flowsheet for 6/17/2024 revealed, the patient dialysate treatment was verified by two staff members, including Certified Clinical Hemodialysis Technician, Staff A. During a surveyor observation in the presence of Staff A on 6/17/2024 at 1:45 PM, the patient was observed receiving dialysate with potassium of 3.0 and not the potassium 2.0 that was prescribed for him/her. During a surveyor interview immediately following the above observation with Staff A, she acknowledged that the patient was receiving his/her dialysate with potassium 3.0 instead of 2.0, as ordered. Staff A further indicated that the patient had began receiving his/her treatment at 12:37 PM. During a surveyor interview with the Clinical Manager on 6/17/2024 at 1:57 PM, she indicated that she would expect the staff to follow the prescribed dialysis treatment, as ordered. Additionally, the manager indicated that she would have expected the two staff members that verified the patient’s dialysate treatment prior to initiating the treatment to have identified the error.”